OMB
No.
XXXX­
XXXX
Expires
XX/
XX/
XXXX
EPA
FORM
5300­
26
U.
S.
ENVIRONMENTAL
PROTECTION
AGENCY
Quality
Assurance
Reporting
Form
for
Use
by
Recipients
of
Assistance
Agreements
EPA
Award
Number:

Recipient
Organization:

Name:
Address:
Project/
Program
Period(
starting
and
ending
dates,
mm/
dd/
yyyy):

Activity
Group:

(
check
all
that
apply)
 
Infrastructure
Development
 
Data
Exchange,
Analysis
and
Integration
 
Planning,
Mentoring,
and
Training
 
Challenge
Goal
Task
Output
Outcome
Quality
Assurance
Measures
Instructions:
­
Please
submit
electronically
to
exchangenetwork@
epa.
gov
within
90
days
of
award.

­
For
Quality
Assurance
Measures,
please
refer
to
Solicitation
Notice
Appendix
D:
Quality
Assurance
Guidelines.

­
For
Goals,
please
refer
to
goals
outlined
in
your
assistance
agreement
work
plan.
