Planning, Training, and Exercise – Annual Workplan

OMB Control No:	0970-0474
Expiration Date:
Estimated Burden:	30 minutes

U.S. REPATRIATION PROGRAM
ANNUAL WORKPLAN

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to determine eligibility for temporary assistance under the U.S. Repatriation Program during an emergency repatriation. Public reporting burden for this collection of information is estimated to average 0.5 hours per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required to obtain a benefit (42 U.S.C. Section 1313). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0474 and the expiration date is xx/xx/xxxx. If you have any comments on this collection of information, please contact the U.S. Repatriation Program, 330 C St. SW, Washington, D.C. 20201.

SECTION I: STATE AND AGENCY NAME
1. State Name	2. Agency Name
SECTION II: ANNUAL WORKPLAN
3. Federal Fiscal Year (MM/DD/YYYY to MM/DD/YYYY) to
SECTION III: ACTIVITIES
4. Activity #1
Name of Activity	Type of Activity (select all that apply) ¨ Planning ¨ Training ¨ Exercises
Description of Activity
Activity Deliverables 1. 2. 3.
5. Activity #2
Name of Activity	Type of Activity (select all that apply) ¨ Planning ¨ Training ¨ Exercises
Description of Activity
Activity Deliverables 1. 2. 3.
6. Activity #3
Name of Activity	Type of Activity (select all that apply) ¨ Planning ¨ Training ¨ Exercises
Description of Activity
Activity Deliverables 1. 2. 3.
7. Activity #4
Name of Activity	Type of Activity (select all that apply) ¨ Planning ¨ Training ¨ Exercises
Description of Activity
Activity Deliverables 1. 2. 3.

GENERAL INFORMATION

Purpose: This form is to provide an annual workplan for each federal fiscal year for emergency repatriation planning, training, and exercises.

Who Should Complete this Form: An official authorized by the state.

When to Submit: Submit with initial application and with each non-competing continuation application.

Where to Submit: Include with initial application, with cc to OHSEPR-Repatriation@acf.hhs.gov and OHSEPR-Grants@acf.hhs.gov.

SPECIFIC INSTRUCTIONS

SECTION I: STATE AND AGENCY NAME

Item 1. State Name. Provide the name of the state.

Item 2. Agency Name. Provide the full name of the state agency and relevant office.

SECTION II: ANNUAL WORKPLAN

Item 3. Federal Fiscal Year (MM/DD/YYYY to MM/DD/YYYY). Enter the federal fiscal year dates covered for this workplan (e.g., 09/30/20xx to 09/29/20xx).

SECTION III: ACTIVITIES

Item 4. Activity #1. List activities for the listed federal fiscal year. Complete items for each activity. If more space is needed, attach additional pages.

Name of Activity. Provide a name for the activity (e.g., Tabletop Exercise of Current Plan, Training Development on Emergency Repatriation for State Staff, State Emergency Repatriation Plan Update, etc.)

Type of Activity. Select all that apply for the specific activity. See the Planning, Training, and Exercises Information Memorandum (OHSEPR-IM-2023-01) for descriptions of activities.

Description of Activity. Provide a brief description of the activity (e.g., tabletop exercise, functional exercise, State Emergency Repatriation Plan revision, emergency repatriation training). Include proposed milestones, tentative dates, and other state agencies that may participate in the activity. For trainings, provide the topic(s), format (e.g., in person, webinar), and type of audience (e.g., state staff personnel, non-governmental organizations).

Activity Deliverables. Identify deliverables from each activity (e.g., revised State Emergency Repatriation Plan, trainings or materials, exercise plan, master scenario events list, after action meeting and report, etc.).

Item 5. Activity #2. See instructions for Item 4.

Item 6. Activity #3. See instructions for Item 4.

Item 7. Activity #4. See instructions for Item 4.

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