Research and Assessment Generic Request Template

SAMHSA 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

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

BURDEN HOURS COMPUTATION

1