Information Collection

SCSEP Community Service Assignment Form (State)

IC 181007 under ICR 201103-1205-009 · OMB 1205-0040.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0040 can be found here:

Documents and Forms

Document Name Document Type
Form ETA-9121 SCSEP Community Service Assignment Form (State) Form
ETA-9121 Community Service Assignment Form SPARQ CSA Form ETA-9121_5 12 09 (2).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SCSEP Community Service Assignment Form (State)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR Part 641 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	ETA-9121	Community Service Assignment Form	SPARQ CSA Form ETA-9121_5 12 09 (2).pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	98,670	70,071	28,599
Annual IC Time Burden (Hours)	9,867	7,007	2,860
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.