Revised 9/1/2006 1

PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part II: Information Collection Detail

IMPORTANT: A separate Part II must be completed for each Information Collection (IC) activity associated with the ICR. If more than one 

Part II is required, create a separate Part II document for each IC. For more information see OEI’s ICR website at 

http://intranet.epa.gov/icrintra/. There you will find information on completing this form (see OEI’s ICRAS instructions under the Prepare an 

ICR tab) and information on how break your ICR into ICs (see OMB’s ROCIS IC Q&A under the Download Guidance tab).

1. Title of Information Collection: National Emission Standards for Hazardous Air Pollutants Emissions: Polyether Polyols Production

2. Is this a common form? 

 Yes

 No

(Select Yes to identify forms that EPA is 

willing to host for potential use by other 

Federal Agencies.)

3. Obligation to respond (check one):

 Voluntary

 Required to obtain or retain benefits

 Mandatory

Note: Only one selection may be made. If multiple 

categories apply, you must create additional ICs to 

account for the burden associated with each 

category.

4. Frequency of reporting (only to be completed if 

there are reporting requirements, check all that 

apply): 

 Hourly

 Daily

 Weekly

 Monthly

 Yearly

 Every Decade

 Quarterly

 Semi-Annually

 Biennially

 Once

 Occasionally

5. CFR Citation(s) for the information collection under review (if applicable):

Title 40 Part 63 Section 1420-1439 

Title Part Section 

Title Part Section 

Title Part Section 

6. Information Collection Instruments/Forms (if applicable) :

Form Name: 

Form Number: 

URL (required if electronic) : 

Is this form available electronically? Yes No If yes, can this form be submitted electronically? Yes No

Form Name: 

Form Number: 

URL (required if electronic) : 

Is this form available electronically? Yes No If yes, can this form be submitted electronically? Yes No

Form Name: 

Form Number: 

URL (required if electronic) : 

Is this form available electronically? Yes No If yes, can this form be submitted electronically? Yes No

Attach additional sheets if necessary.

Note: Instruments/Forms must be submitted/uploaded as a separate attachment.
Revised 9/1/2006 2

7. Federal Enterprise Architecture Business Reference Model:

Line of Business (check one) : Subfunction (check one) :

 Environmental Management Environmental Monitoring and Forecasting

 Environmental Remediation

 Pollution Prevention and Control

Health Illness Prevention

 Immunization Management

 Public Health Monitoring

 Health Care Services

 Consumer Health and Safety

 Natural Resources Water Resource Management

 Conservation, Marine and Land Management

 Recreational Resource Management and Tourism

 Agricultural Innovation and Services

Note: Most EPA ICRs will be aligned with the Environmental Management FEA Line of Business. Other likely categories are also listed. For a full 

listing of the FEA Business Reference Model categories and definitions, see:

http://www.whitehouse.gov/omb/egov/documents/FY07_Ref_Model_Mapping_QuickGuide.pdf.

8. Privacy Act System of Records (if applicable) :

Title: 

Federal Register Citation: Volume Page Number Publication Date 

9. Respondents

Total Number: 23

Small Entity Number: 0

Percentage of responses collected electronically: 20

Affected Public (check one) :

 Individuals or Households

 Private Sector (if private sector, check all that apply)

 Business or other for-profit

 Not-for-profit institutions

 Farms

 State, Local, or Tribal Governments

 Federal Government

Note: Only one selection may be made. If multiple categories apply, you 

must create additional ICs to account for the burden associated with each 

category. Selecting multiple subcategories within “Private Sector” will not 

affect then number of ICs required.

10. Frequency: How often on average will each respondent respond 

to the Information Collection?

Calculated Annual Frequency: 2.1

 (responses per respondent per year)

Calculated Annual Number of Responses: 48.7

Number of Respondents 23 per 

 

 

 

 Year

 Hour Business hour

 Day Business Day

 Week Month

 Decade Quarter

 Half-year

11. Hour and Cost Burden: Enter the hours and cost (per response) broken out by reporting, record keeping, and third party disclosure:

Hours per Response Total Annual Hour Burden Cost per Response Total Annual Cost Burden

Reporting 28 1,373 $12,711 $618,631

Recordkeeping 0 2,328 0 0

Third Party Disclosure 0 0 0 0

Total 28 3,701 $12,711 $618,631

IMPORTANT: “Cost per Response” and “Total Annual Cost Burden” should include Capital/Startup and O&M costs only.
Revised 9/1/2006 3

12. Annual Responses and Burden Change

Total Requested

Program Change 

due to New 

Statute

Program Change 

due to Agency 

Discretion

Change due to 

Adjustment in 

Agency Estimate

Change due to 

Violation of the 

PRA

Currently 

Approved

Annual 

Responses 48.7

Annual Hour 

Burden 3,701

Annual Cost 

Burden $618,631