Office of Head Start Tribal Consultations

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OMB Control Number: 0970-0617
Expiration date: XX/XX/XXXX
Office of Head Start Tribal Consultations Registration Form
Paperwork Reduction Act Statement: 
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to gather appropriate information to plan Office of Head Start (OHS) Tribal Consultations. Public reporting burden for this collection of information is estimated to average one (1) minute, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0617 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact [email protected]. 

Question Sub-Category
Question Text Options
Response Type or Option Set
Registration Type 
-- Registration type
List of registration types: {Federal Employee, Federal Contractor, Tribal Leader, Authorized Designee, Tribal Head Start Staff member, Other/textbox}
Name
-- First Name
-- Last Name
Textbox
Role/Title
-- Role/Title
Textbox

Tribal Affiliation
-- Tribal Affiliation
Textbox
Organization
-- Organization/Agency Name

Textbox 
City
-- City
Textbox
State
-- State/Territory
List of applicable states/territories 
Phone Number
-- Phone Number
Textbox
E-mail
-- E-mail

Textbox
Accommodations
-- Please describe any accommodations that will facilitate your full participation in this event 
Textbox  
Language 
In which language would you like to register? 
-- Preferred language
Textbox
Oral Testimony
-- Do you intend to provide oral testimony at the event? (Note: In order to provide testimony, you must be a Tribal Leader or an Authorized Designee that has submitted a signed letter to {email address/contact information} before {date} to speak on behalf of the Tribe.)
Yes/No
Written Testimony
-- Do you intend to provide written testimony for the Consultation Report? (Note: Tribes wishing to submit written testimony for the Consultation Report may submit it to ACF prior to the consultation session or within 30 days after the session. When possible, please submit written testimony at least 3 days in advance of the consultation. Written testimony may be submitted to {email address/contact information}.)
Yes/No