HS_Eligibility_Verification_Form_Supporting_Statement_(2)_OHS_rev_13013 rev_20113

THE SUPPORTING STATEMENT

Specific Instructions

A. Justification

1. Circumstances Making the Collection of Information Necessary

The requirements for establishing proof of eligibility for the enrollment of children in Head Start programs are documented in 45 CFR 1305.4 (e). The regulation states that each child's record must include a signed document by an employee identifying those documents which were reviewed to determine eligibility and stating that the child is eligible to participate in the program. Presently there is no standardized document for grantees to use and OHS developed this sample form to assist grantees in information collection. This sample form could be used to facilitate an efficient and accurate determination and documentation of childrens' eligibility for Head Start. However, Head Start programs are not required to use this specific form. Grantees may adapt this sample form or design a form that is relevant to their program in order to meet the requirement in 45 CFR 1305.4 (e).

2. Purpose and Use of the Information Collection

The Head Start Eligibility Verification form will be completed by grantees according to 1305.4(e) and maintained in each child’s file.

3. Use of Improved Information Technology and Burden Reduction

This form can be completed electronically. A standardized form streamlines this important process and therefore reduces burden at the grantee level. When all grantees use the same form, federal burden is also reduced because compliance assessment is more easily done.

4. Efforts to Identify Duplication and Use of Similar Information

This is a sponsored information collection, not a survey, which will be used to collect information required by regulation. Duplication or use of similar information is not an issue. If at all, having a standardized form eases the process and reduces the likelihood that a form will need to be re-done.

5. Impact on Small Businesses or Other Small Entities

This information collection should not have any impact on small businesses or other small entities.

6. Consequences of Collecting the Information Less Frequently

This does not apply, as this is nor a survey. This information must be gathered for every child enrolled in a Head Start program, anyway; this form eases that process. use of this form will increase the likelihood of grantee compliance with these important regulations, and reduce the likelihood repeat record-keeping.

7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

There are no special circumstances.

8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency

A 60 day notice was published on March 7, 2012. No comments were received.

A 30 day notice was published on November 20, 2012. Three comments were received. All three comments stated that Head Start providers should be allowed to develop and use their own eligibility verification form following the model of OMB 0907-0374, rather than having to use the specific form 0907-0374.

We did not make any changes to the form based on these comments. The Head Start Eligibility Verification Form is a sample form for grantees to use. It is not mandatory.

9. Explanation of Any Payment or Gift to Respondents

There will be no payment or gift to respondents.

10. Assurance of Confidentiality Provided to Respondents

This is a sponsored information collection, and this document will be maintained on site at the grantee. They are not collected by the government.

11. Justification for Sensitive Questions

There are no sensitive questions.

12. Estimates of Annualized Burden Hours and Costs

Instrument	Number of Respondents	Number of Responses per Respondent	Average Burden Hours per Response	Total Burden Hours
Head Start Eligibility Verification	1,600	750	0.08	96,000

Estimated Total Annual Burden Hours: 96,000

13. Estimates of Other Total Annual Cost Burden to Respondents and Record Keepers

$0

14. Annualized Cost to the Federal Government

$0

15. Explanation for Program Changes or Adjustments

This is a continuation of an existing project.

16. Plans for Tabulation and Publication and Project Time Schedule

These will not be published.

17. Reason(s) Display of OMB Expiration Date is Inappropriate

N/A

18. Exceptions to Certification for Paperwork Reduction Act Submissions

B. Statistical Methods (used for collection of information employing statistical methods)

This information collection does not employ statistical methods.

1. Respondent Universe and Sampling Methods

2. Procedures for the Collection of Information

3. Methods to Maximize Response Rates and Deal with Nonresponse

4. Test of Procedures or Methods to be Undertaken

5. Individuals Consulted on Statistical Aspects and Individuals Collecting and/or Analyzing Data