                                 Attachment H
                        Template for 18 Question Format
               Supporting Statement for a Request for OMB Review
                       under the Paperwork Reduction Act
Executive Summary 
Identification of the Information Collection  -  Title and Numbers
      [Title]
      [ICR Numbers]
      [Docket ID No.]
Abstract 
Supporting Statement 
1. Explain the circumstances that make the collection of information necessary. 
	[Requirements under the Statute]
2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the Agency has made of the information received from the current collection.
	[Description of how the data will be used]
3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses.
	[Description of implementing regulations and how the information will be collected, i.e. CDX]
4. Describe efforts to identify duplication
	[Collection process and uniqueness to the Agency]
5. If the collection of information impacts small businesses or other small entities, describe the methods used to minimize burden.
	[Describe steps Agency has taken to reduce impact on small business, or if no impact on small businesses]
6. Describe the consequence to Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.
	[Frequency of collection]
7. Explain any special circumstances that require the collection to be conducted in a manner inconsistent with OMB guidelines.
	[Impacts on PRA]
8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken in response to the comments. Specifically address comments received on cost and hour burden. Describe efforts to consult with persons outside EPA to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or report.
	[Consultations, public review and comment]
[placeholder for consultation for 1[st] FRN: 
Pursuant to 5 CFR 1320.8(d) in proposing to renew this ICR, EPA will publish a notice in the Federal Register that will provide a 60-day public comment period. The comments received and any additional public comment for this action will be posted in the docket. 
As required under 5 CFR 1320.8(d)(1), in addition to the public notice EPA staff will contact appropriate stakeholders and ask them for their assessment of the regulatory burden estimates expressed by the Agency in this ICR. A summary of these consultations will be provided in the supporting statement during the second comment period. The full consultation will be reserved in Attachment [X].]
[placeholder for consultation for 2[nd] FRN: 
[EPA consulted with the following entities (no PII) and had x comments] 
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
	[Not applicable]
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.
	[Describe process to handle and protect CBI]
11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.
      [No information of a sensitive or private nature is requested in conjunction with these information collection activities, and these information collection activities comply with the provisions of the Privacy Act of 1974 and OMB Circular A-108.]
12. Provide estimates of the hour burden of the collection of information.
	[Description of collection by statute or regulation, NAICS codes, respondent activities, and tables of burden]
13.  Provide an estimate for the total annual cost burden to respondents or recordkeepers resulting from the collection of information.
	[Statement of burden and references to previous tables or Appendix]
14. Provide estimates of annualized cost to the Federal government.
      [Description of collection by statute or regulation, Agency activities, and tables of burden]
15. Explain the reasons for any program changes or adjustments reported in Items 13 (or 14) of OMB Form 83-I.
	[Description of any change in burden and tables]
16. For collections whose results will be published, outline the plans for tabulation and publication.
	[Schedule for collection, i.e. quarterly, once a year, every other year, every four years, or "on occasion"]
17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons why display would be inappropriate.
	[Not applicable]
18. Explain each exception to the certification statement identified in Item 19 of OMB Form 83-I.
	[EPA does not request an exception to the certification of this information collection.]
List of References, Attachments & Appendices 


















