Short Statement

DOCUMENTATION FOR THE GENERIC CLEARANCE

FOR THE COLLECTION OF QUALITATIVE RESEARCH & ASSESSMENT

TITLE OF INFORMATION COLLECTION:

[ ] INTERVIEWS

[ ] SMALL DISCUSSION GROUPS

[ ] FOCUS GROUPS

[ ] QUESTIONNAIRES

[ ] OTHER (EXPLAIN: )

DESCRIPTION OF THIS SPECIFIC COLLECTION

1. Intended purpose

2. Need for the collection

3. Planned use of the data

4. Date(s) and location(s)

5. Collection procedures

6. Number of collections (e.g., focus groups, surveys, sessions)

7. Description of respondents/participants

8. Description of how results will be used

9. Description of how results will or will not be disseminated and why or why not

AMOUNT OF ANY PROPOSED STIPEND OR INCENTIVE – NONE

BURDEN HOUR COMPUTATION (Number of responses (X) estimated response or participation time in minutes (/60) = annual burden hours):

Category of Respondent	No. of Respondents	Participation Time	Burden

BURDEN COST COMPUTATION

Category of Respondent	No. of Respondents	Hourly Rate	Response Time	Total

OTHER SUPPORTING INFORMATION

REQUESTED APPROVAL DATE:

NAME OF CONTACT PERSON:

TELEPHONE NUMBER:

DEPARTMENT/OFFICE/BUREAU:

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