Change Worksheet

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/Subagency       U.S. Department of Education, Office of Innovation and Improvement (OII)		OMB Control Number     -    1855-0021
Enter only items that change Current Record New Record
Agency form number(s)	     	     
Annual reporting and record keeping hour burden
Number of respondents	     	     No change
Total annual responses	     	     
Percent of these responses collected electronically	     	     
Total annual hours	     	No change in Burden     
Difference		     
Explanation of difference Program Chage		     
Adjustment		     
Annual reporting and record keeping cost burden (in thousands of dollars)
Total annualized capital/startup costs	     	     
Total annual costs (O&M)	     	     
Total annualized cost requested	     	     
Difference		     
Explanation of difference Program Change		     
Adjustment		     
Other change**       This request is processed to move the application to the IC page, and other documents to the proper location in the record
Signature of Senior Officer or designee:      	Date:      	For OIRA Use            

**This form cannot be used to extend an expiration date

OMB 83-C