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OMB Control No: 0970-0374	ICR Reference No: 201903-0970-004
Status: Historical Active	Previous ICR Reference No: 201512-0970-004
Agency/Subagency: HHS/ACF	Agency Tracking No: OHS
Title: Head Start Eligibility Verification
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/29/2019
	Date Received in OIRA: 03/27/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2022	36 Months From Approved	04/30/2019
Responses	673,672	0	768,020
Time Burden (Hours)	16,842	0	124,520
Cost Burden (Dollars)	0	0	0

Abstract: The Head Start Program Performance Standards (HSPPS) regulations on eligibility in 45 CFR 1302.12 is published under the authority granted to the Secretary of Health and Human Services under the Head Start Act, as amended, (42 USC 9801 et seq) at sections 644(c), 645(a)(1)(A), and 645A(c). There is no standardized document for grantees to use for any of the eligibility determination requirements in 45 CFR 1302.12. Still, OHS developed this sample form to assist grantees in collecting information to meet record keeping requirements for eligibility determination records. The sample form facilitates an efficient and accurate determination and documentation of 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 requirements. Programs must store eligibility determination records as long as the child is enrolled and for one year after they have either stopped receiving services or are no longer enrolled. They can be maintained electronically or in hard copy. This form can be part of that eligibility determination record alongside other documentation required as part the record. The Office of Head Start is requesting an extension, with changes, of the Head Start Eligibility Verification. Changes are minor and provide some additional clarification to the form.

Authorizing Statute(s): PL: Pub.L. 110 - 134 644(c); 645(a)(1)(A); 645A(c) Name of Law: Head Start Act, as amended

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 65678	12/21/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 11304	03/26/2019
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
1305.4(d)(2)
1305.4(h),(i),, and (j)
1305.4(l) Other Record Keeping
Eligibility Verification Form	1

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	673,672	768,020	-94,348
Annual Time Burden (Hours)	16,842	124,520	-107,678
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The overall burden has been greatly reduced due to the revised HSPPS. The previously approved information collection under this OMB # had a calculated burden of 124,520 hours. This covered the burden to complete the full eligibility determination record, which included filling out the form itself among other record keeping requirements from the prior HSPPS. These record keeping requirements and the burden associated were addressed and accounted for during the rule-making process of the new HSPPS (see Federal Register Notice 81 FR 61293 and OMB #0970-0148 for burden approved under the new HSPPS). The only burden associated with this revised information collection request is now the standalone estimated burden in filling out the form which is estimated to take 1.5 minutes per response. There is a slight decrease to the annual number of respondents. The annualized cost in section A12 was updated per new OMB guidance.

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Molly Buck 202 205-4724 mary.buck@acf.hhs.gov

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