INSTRUCTIONS: Use this form when a single information collection document involves multiple reporting and recordkeeping requirements.
NOTE: The columns will calculate automatically. If Col. E's response is something other than annually, i.e., 1/6 years, list as "1/6" & decimal will display.
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TITLE OF INFORMATION COLLECTION DOCUMENT |
OMB NO. |
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| Certified State Mediation Program |
0560-165 |
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| DATE PREPARED |
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| September 5, 2023 |
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| IDENTIFICATION OF REPORTING OR RECORDKEEPING REQUIREMENT |
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ANNUAL BURDEN |
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REPORTS |
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RECORDS |
RESPONDENT COST |
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TOTAL BURDEN HOURS |
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TOTAL |
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FORMS NO (S) |
NO. OF |
NO OF |
TOTAL ANNUAL |
HOURS |
(Col. F x G) |
NO. OF |
ANNUAL |
RECORD- |
COST |
TOTAL |
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| SECTION OF |
DESCRIPTION |
(If "none" |
RESPONDENTS |
RESPONSES |
RESPONSES |
PER |
(H) |
RECORD- |
HOURS PER |
KEEPING HOURS |
PER |
COST |
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| REGS. |
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so state) |
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PER |
(Col. D x E) |
RESPONSE |
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KEEPERS |
RECORD- |
(Col. I x J) |
HOUR |
(Col. H x L) |
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RESPONDENT |
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EXEMPT |
NON-EXEMPT |
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KEEPER |
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| (A) |
(B) |
(C) |
(D) |
(E) |
(F) |
(G) |
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(I) |
(J) |
(K) |
(L) |
(M) |
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| 785.3(b) |
Recertification |
None |
42 |
3 |
126 |
7.00 |
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882 |
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$105.00 |
6,174 |
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| 785.8(a) |
Annual Report |
None |
42 |
3 |
126 |
10.00 |
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1,260 |
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$105.00 |
132,300 |
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| 785.8(b) |
Mid-Year Report |
None |
42 |
3 |
126 |
5.00 |
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630 |
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$105.00 |
66,150 |
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| 785.4 |
Request for Advance or Reimbursement (OMB # 4040-0012) |
SF-270 |
42 |
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| 785.4(b) |
Application for Federal Assistance** (OMB#4040-0020) |
SF-424 |
42 |
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| 785.4 |
Budget Information for Non-Construction*** (OMB #4040-0006) |
SF-424A |
42 |
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| 785.4 |
Assurances Non-Construction** (OMB #4040-0007) |
SF-424B |
42 |
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| 785.4 |
Federal Financial Report*** (OMB #4040-0014) |
SF-425 |
42 |
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**Collection is included in Recertification Request |
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***Collection is included in the Annual Report |
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378 |
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2,772 |
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0.00 |
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204,624 |
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TOTAL OF ALL PAGES |
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378 |
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2,772 |
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0.00 |
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204,624 |
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| TOTAL - COLUMNS "F" AND "I" = OMB 83-I, 13b; COLUMNS "H" AND "K" = OMB 83-I, 13c |
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378 |
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2,772 |
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