                     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: "This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2025-0006). Responses to this collection of information are mandatory (2 CFR Part 200). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 2.6 hours per response for the Quality Assurance Reporting Form. 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 to the Regulatory Support Division Director, U.S.

