Attachment A: Submission Template for Monitoring Generic

Request for Approval under the clearance of the “Generic for ACF Program Office Monitoring Activities” Office of Management and Budget (OMB) Control Number: 0970-0XXX

TITLE OF INFORMATION COLLECTION:

PURPOSE:

DESCRIPTION OF RESPONDENTS: (e.g., states, grantees, or type of non-profit)

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary and in compliance with U.S. Health and Human Services regulations.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

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

4. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

Name:________________________________________________

To assist OMB review of your request, 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 been published? [ ] Yes [ ] No

BURDEN HOURS

Category of Respondent	No. of Respondents	No. of Responses per Respondent per year	Burden per Response	Annual Burden
Totals

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

TYPE OF COLLECTION:

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

[ ] Web-based

[ ] E-mail

[ ] Paper mail

[ ] Other, Explain

Please make sure to submit all instruments, instructions, and scripts with the request.

Instructions for completing Request for Approval under the “Generic for ACF Program Office Monitoring Activities”

Monitoring forms approved under this Generic must display the required Paperwork Reduction Act information, which includes the following:

1. On the upper right of the first page: OMB Control Number: 0970-05XX, Expiration Date: XX/XX/2023.

2. At the bottom of the first page, include the following language. For red text in brackets, choose the best option and delete the other bracketed option(s). Replace highlighted areas with content specific to your collection.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: [Through this information collection, ACF is gathering information to….]/[The purpose of this information collection is to….] Public reporting burden for this collection of information is estimated to average XX hours per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. [This is a voluntary collection of information.]/[This is a mandatory collection of information (cite authority)]. [This collection of information is required to retain a benefit (cite authority)]. 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 0970-0XXX and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact….

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request.

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information.

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.

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.

No. of Responses per Respondent: Provide the number of responses per respondent per year.

Burden per Response: Provide an estimate of the amount of time required for a respondent to participate (e.g., complete all information requested in a monitoring form).

Burden: Provide the Annual Burden Hours.

FEDERAL COST: Provide an estimate of the annual cost to the Federal Government.

TYPE OF COLLECTION: Check all that apply.

Submit all instruments, instructions, and scripts with the request.

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