genIC Request Template

Request for genIC Approval

Performance Measures Project

0920-xxxx

CIO:

PROJECT TITLE:

PURPOSE AND USE OF COLLECTION:

NUMBER AND TITLE OF NOFO:

NUMBER OF PARTICIPATING RECIPIENTS:

DESCRIPTION OF NOFO (check all that apply):

__ Funds all 50 states

__ Has budget higher than $10 million per year

__ Has significant stakeholder interest (e.g. partners, Congress)

Please elaborate:

PERFORMANCE METRICS USED & JUSTIFICATIONS:

CERTIFICATION:

I certify the following to be true:

1. The collection is non-controversial and does not raise issues of concern to other federal agencies.

2. Information gathered is meant primarily for program improvement and accountability; it is not intended to be used as the principal basis for policy decisions

Name: ________________________________________________

To assist review, please answer the following questions:

BURDEN HOURS

Category of Respondent	Form Name	No. of Respondents	Participation Time (minutes)	Burden in Hours
Totals

FEDERAL COST: The estimated annual cost to the Federal government is ____________

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based

[ ] Email

[ ] Postal Mail

[ ] Other, Explain

Please make sure all instruments, instructions, and scripts are submitted with the request.

Instructions for completing genIC Request for Approval for

Performance Measurements Project

Project Title: Provide the name of the collection that is requested.

PURPOSE AND USE OF COLLECTION: 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.

NUMBER AND TITLE OF NOFO: Provide federal grant or other identifying number and title

NUMBER OF PARTICIPATING RECIPIENTS: Enter number of recipient organizations

DESCRIPTION OF NOFO: Briefly describe the key programmatic activities and the targeted group/groups for this collection.

PERFORMANCE METRICS USED & JUSTIFICATIONS: Describe the changes to the sample forms and justifications for metrics selected

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

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; (4) Federal Government or Non-Governmental Organizations. Only one type of respondent can be selected.

Form Name: Provide the title of the information collection form.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to complete the form

Burden in Minutes: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Estimate the annual cost to the Federal government for this collection.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked.

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