

                     U.S. ENVIRONMENTAL PROTECTION AGENCY
                       Quality Assurance Reporting Form
                for Use by Recipients of Assistance Agreements
Recipient Organization: 
Name:
Address:

EPA Award Number:


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 your EPA Regional Project Officer within 90 days of award.
                           - For Quality Assurance Measures, please refer to most recent Solicitation Notice for Quality Assurance Guidelines.
                           - For Goals, please refer to goals outlined in your assistance agreement work plan.
Paperwork Reduction Act (PRA) Burden Statement:  The public reporting and recordkeeping burden for this collection of information is estimated to average one hour per response.  Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.  Include the OMB control number in any correspondence.  Do not send the completed form to this address.

