Grants Program Monitoring Activities Generic Submission form

Request for Approval under the “Generic Clearance for Grants Program Monitoring Activities” (OMB Control Number: 0930-NEW)

TITLE OF INFORMATION COLLECTION:

PURPOSE:

DESCRIPTION OF RESPONDENTS:

TYPE OF COLLECTION: (Check one)

[ ] Progress Report Template (Annual) [ ] Site Visit Report Template

[ ] Progress Report (Interim) [ ] Grant Closeouts

[ ] Other: ______________________

CERTIFICATION:

I certify the following to be true:

1. The collection is in compliance with HHS regulations.

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

3. Information gathered is meant primarily for program improvement and accountability.

Name:________________________________________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [ ] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No

BURDEN HOURS

Category of Respondents	Number of Respondents	Number of Responses	Total Responses	Hours per Response	Total Hours
Total

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 or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

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