fast-track-PRA-submission-short-form ANA

Request for Approval under the “Generic Clearance for the Collection of Routine Customer
Feedback” (OMB Control Number: 0970-0401)
TITLE OF INFORMATION COLLECTION:
2014 ACF Native American Grantee Conference
PURPOSE: The Administration for Children and Families is planning an agency wide
conference for its Native American Grantees, to be held in Washington, D.C. The tentative dates
are June 17-19, 2014 with June 16 open for the ACF Annual Tribal Consultation session and
June 20 open for individual program office meetings.
All ACF program offices will be a part of this conference. Other HHS offices including CMS,
CDC, SAMHSA, IHS, HRSA and other Federal Agencies such as Dept. of Justice, Dept. of
Interior, BIA and BIE will also participate. The conference theme is ACF: Honoring Our
Commitments to Native Families and Communities Today and Tomorrow. ACF is requesting
input on plenary and workshop sessions. Respondents are asked to complete the survey so ACF
can plan the conference around topics of specific interest to participants and the communities
they serve.
This is a request for approval by the Office of Management and Budget (OMB), under the
Federal Paperwork Reduction Act of 1995, for a new data collection task to be added to the
Administration for Children and Families’ already approved generic OMB clearance # 09700401. The proposed information collection activity includes delivering voluntary and anonymous
online satisfaction surveys to invitees to ACF’s 2014 Grantee Meeting.
Data collected from the proposed Survey will be used to better understand suggestions ACF
grantees have for the 2014 ACF Grantee Meeting. This information, in turn, will be used by the
Administration for Native Americans as well as other components within ACF to better meet the
needs of grantees attending and benefitting from the 2014 ACF Grantee Meeting.
DESCRIPTION OF RESPONDENTS: Survey respondents will tribal governments, Indian
Tribes and tribal organizations, Alaska Native grantees, and non-profit Native American
organizations funded by ACF. An estimate of the annual response burden is outline in the
following table.
TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[] Customer Satisfaction Survey
[ ] Small Discussion Group
[X ] Other: ______________________

CERTIFICATION:
I certify the following to be true:
1. The collection is voluntary.
2. The collection is low-burden for respondents and low-cost for the Federal Government.

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3. The collection is non-controversial and does not raise issues of concern to other federal
agencies.
4. The results are not intended to be disseminated to the public.
5. Information gathered will not be used for the purpose of substantially informing influential
policy decisions.
6. The collection is targeted to the solicitation of opinions from respondents who have
experience with the program or may have experience with the program in the future.
Name: [email protected] or [email protected]

To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [X ] No
2. If Yes, will any information that is collected be included in records that are subject to the
Privacy Act of 1974? [ ] Yes [ X ] No
3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No
Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to
participants? [ ] Yes [X] No
BURDEN HOURS
Category of Respondent

No. of
Participation
Respondents Time
0.052
0.052
0.052

State, local, or tribal governments
Private sector
Federal Government
Totals

Burden
1.3
1.3
.52
3.12

FEDERAL COST: The estimated annual cost to the Federal government is approximately $0
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
The selection of your targeted respondents
1. Do you have a customer list or something similar that defines the universe of potential
respondents and do you have a sampling plan for selecting from this universe?
[ ] Yes [X] No
If the answer is yes, please provide a description of both below (or attach the sampling plan)? If
the answer is no, please provide a description of how you plan to identify your potential group of
respondents and how you will select them?

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The above figures are based on an estimate of approximately 0.052 hour per response to respond
and submit each online survey. The potential group of respondents is based on individual offices
with tribal grantees listservs. The survey will be sent out to these grantees requesting their input.
Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[X] Web-based or other forms of Social Media
[ ] Telephone
[ ] In-person
[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ ] Yes [X] No
Please make sure that all instruments, instructions, and scripts are submitted with the
request.
Instructions for completing Request for Approval under the “Generic Clearance for the
Collection of Routine Customer Feedback”
TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the
subject of the request. (e.g. Comment card for soliciting feedback on xxxx)
PURPOSE: Provide a brief description of the purpose of this collection and how it will be used.
If this is part of a larger study or effort, please include this in your explanation.
DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or
groups for this collection of information. These groups must have experience with the program.
TYPE OF COLLECTION: Check one box. If you are requesting approval of other
instruments under the generic, you must complete a form for each instrument.
CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the
collection will be returned as improperly submitted or it will be disapproved.
Personally Identifiable Information: Provide answers to the questions. Note: Agencies
should only collect PII to the extent necessary, and they should only retain PII for the period of
time that is necessary to achieve a specific objective.
Gifts or Payments: If you answer yes to the question, please describe the incentive and provide
a justification for the amount.
BURDEN HOURS:
Category of Respondents: Identify who you expect the respondents to be in terms of the
following categories: (1) Individuals or Households; (2) Private Sector; (3) State, local, or tribal
governments; or (4) Federal Government. Only one type of respondent can be selected per row.
No. of Respondents: Provide an estimate of the Number of Respondents.
Participation Time: Provide an estimate of the amount of time (in minutes) required for a
respondent to participate (e.g. fill out a survey or participate in a focus group)

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Burden: Provide the Annual burden hours: Multiply the Number of Respondents and the
Participation Time then divide by 60.
FEDERAL COST: Provide an estimate of the annual cost to the Federal government.
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
The selection of your targeted respondents. Please provide a description of how you plan to
identify your potential group of respondents and how you will select them. If the answer is yes,
to the first question, you may provide the sampling plan in an attachment.
Administration of the Instrument: Identify how the information will be collected. More than
one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or
facilitators (e.g., for focus groups) used.
Submit all instruments, instructions, and scripts are submitted with the request.

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