Defense Logistics Agency Child and Youth Program

Forms and Documents

Document Name	Status
Form DLA Form 1855-1F DLA Form 1855-1F Form	Removed
Form DLA Form 1855-1E DLA Form 1855-1E Form	Removed
Form DLA Form 1855-1D P DLA Form 1855-1D Form	Removed
Form DLA Form 1855-1C DLA Form 1855-1C Form	Removed
Form DLA 1855-1B DLA Form 1855-1B Form	Removed
Form DLA Form 1855-1A DLA Form 1855-1A Form	Removed
Form DLA Form 1855 DLA CYP Health Screening/Assessment (DLA Forms 1855/1855-1) Form	Removed
Form DLA Form 1849-4 DLA Form 1849-4 Form	Removed
Form DLA Form 1849-3 DLA Form 1849-3 Form	Removed
Form DLA Form 1849-2 DLA Form 1849-2 Form	Removed
Form DLA Form 1849-1 DLA Form 1849-1 Form	Removed
Form DLA Form 1849 Child and Youth Program Forms Form	Modified
0704-0582_SSA_2.25.2022.docx Supporting Statement A	2022-02-25

IC Document Collections

IC ID	Document Title	Status
234117	DLA Form 1855-1F Form	Removed
234116	DLA Form 1855-1E Form	Removed
234115	DLA Form 1855-1D Form	Removed
234113	DLA Form 1855-1C Form	Removed
234112	DLA Form 1855-1B Form	Removed
234111	DLA Form 1855-1A Form	Removed
234110	DLA CYP Health Screening/Assessment (DLA Forms 1855/1855-1) Form	Removed
234109	DLA Form 1849-4 Form	Removed
234108	DLA Form 1849-3 Form	Removed
234107	DLA Form 1849-2 Form	Removed
234106	DLA Form 1849-1 Form	Removed
234105	Child and Youth Program Forms Form	Modified

ICR Details

OMB Control No: 0704-0582	ICR Reference No: 202202-0704-005
Status: Received in OIRA	Previous ICR Reference No: 201811-0704-003
Agency/Subagency: DOD/DODDEP	Agency Tracking No:
Title: Defense Logistics Agency Child and Youth Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/25/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/28/2022
Responses	12,055	12,055
Time Burden (Hours)	1,005	963
Cost Burden (Dollars)	20,252	21,217

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Abstract: The Department of Defense (DoD) requires the information in the proposed collection in support of Defense Logistics Agency (DLA) Child and Youth Programs (CYPs). This collection includes fourteen (14) DLA forms, some of which are used by all of the collection respondents and some of which are used under specific circumstances. The information collected is used for program planning, management, and health and safety purposes. More specifically, the information in the proposed collection allows CYP staff to provide safe, developmentally appropriate day care services and to ensure proper, effective response in the event of an emergency. Respondents include patrons enrolling their children in a CYP; these patrons may include active duty military, DoD civilian employees, or DoD contractors.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 72585	12/22/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 10346	02/24/2022
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Child and Youth Program Forms	DLA Form 1849, DLA Form 1849-1, DLA Form 1849-2, DLA Form 1849-3, DLA Form 1849-4, DLA Form 1855-1A, DLA Form 1855-1B , DLA Form 1855-1C, DLA Form 1855-1D Part II, DLA Form 1855-1D Part IV, DLA Form 1855-1E, DLA Form 1855, DLA Form 1855-1, DLA Form 1855-1D Part 1, DLA Form 1855-1D Part III, DLA Form 1855-1F	Child and Youth Program (CYP) Medication Consent and Administration Log ,   DLA Child and Youth Program (CYP) Parental Consent for Field Trip ,   DLA CYP Insect Repellent Use Consent ,   DLA CYP Basic Care Item Consent to Apply ,   DLA CYP Child Illness/Injury Readmission Record ,   DLA Child and Youth Program Health/Developmental Screening ,   DLA Child and Youth Program Health Assessment for Enrollment and Renewal ,   DLA Child and Youth Program Respiratory Medical Action Plan ,   DLA Child and Youth Program Special Diet Statement ,   DLA Child and Youth Program Epilepsy/Seizure Medical Action Plan ,   DLA CYP Diabetes Daily Medical Action Plan ,   DLA CYP Diabetes Emergency Medical Action Plan ,   DLA CYP Diabetes Weekly Food and Carbohydrate Log ,   DLA Child and Youth Program Blood Glucose and Ketone Monitoring Log ,   DLA Child and Youth Program (CYP) Allergy Medical Action Plan ,   DLA Child and Youth Program Consent to Perform Caregiving Health Practices and Authorization for Disclosure of Health Information
DLA CYP Health Screening/Assessment (DLA Forms 1855/1855-1)	DLA Form 1855, DLA Form 1855-1	DLA Child and Youth Program (CYP) Health/Developmental Screening ,   DLA Child and Youth Program (CYP) Health Assessment for Enrollment and Renewal
DLA Form 1849-1	DLA Form 1849-1	DLA Child and Youth Program (CYP) Parental Consent for Field Trip
DLA Form 1849-2	DLA Form 1849-2	DLA CYP Insect Repellent Use Consent
DLA Form 1849-3	DLA Form 1849-3	DLA CYP Basic Care Item Consent to Apply
DLA Form 1849-4	DLA Form 1849-4	DLA CYP Child Illness/Injury Readmission Record
DLA Form 1855-1A	DLA Form 1855-1A	DLA Child and Youth Program Respiratory Medical Action Plan
DLA Form 1855-1B	DLA 1855-1B	DLA Child and Youth Program Special Diet Statement
DLA Form 1855-1C	DLA Form 1855-1C	DLA Child and Youth Program Epilepsy/Seizure Medical Action Plan
DLA Form 1855-1D	DLA Form 1855-1D Part 1, DLA Form 1855-1D Part 2	DLA CYP Diabetes Daily Medical Action Plan ,   DLA CYP Diabetes Emergency Medical Action Plan
DLA Form 1855-1E	DLA Form 1855-1E	DLA Child and Youth Program Allergy Medical Action Plan
DLA Form 1855-1F	DLA Form 1855-1F	DLA Child and Youth Program Consent to Perform Caregiving Health Practices and Authorization for Disclosure of Health Information

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	12,055	12,055	0	0	0	0
Annual Time Burden (Hours)	1,005	963	0	42	0	0
Annual Cost Burden (Dollars)	20,252	21,217	0	-965	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The reported time burden has decreased slightly due to a small change in calculation meant to make estimates more accurate. There are no actual changes to the response times for the individual forms. The cost burden on respondents has decreased due to a new, more accurate citation for national median hourly wage.

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Annual Cost to Federal Government: $10,730

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.     Yes

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? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/25/2022

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