CCWIS GenIC Submission Form - Design Self-Assessment Tool

Request for Approval under the clearance of the “Generic CCWIS Review & Technical Assistance” Office of Management and Budget (OMB) Control Number: 0970-0568

TITLE OF INFORMATION COLLECTION: Comprehensive Child Welfare Information System (CCWIS) Review and Technical Assistance Process Self-Assessment Tool: Design Requirements

PURPOSE: The Design Requirements Self-Assessment Tool submitted under this overarching generic clearance will be used by the Children’s Bureau to:

• Proactively identify risks, system shortcomings, or deficiencies in system planning, design, and/or implementation;

• Identify gaps and determine strategies for improvement or corrective action, or to allow a project course change; and,

• Identify the need for additional technical assistance or further federal guidance.

The specific self-assessment tool submitted as part of this generic information collection request is described in the following table:

Topic

Purpose/Use

Design

Used to self-assess the design of CCWIS a system. This may include architecture, software code, data quality, data exchanges, plain language, and modularity. The tool collects information about the underlying design, development, installation, and operation of the information technology system to determine conformance to APD requirements in 45 CFR part 95, subpart F and to determine the extent to which the project meets the requirements in §§ 1355.52, 1355.53, 1355.56, and, if applicable, § 1355.54.

DESCRIPTION OF RESPONDENTS: States and tribes receiving title IV-E funding for a CCWIS.

CERTIFICATION:

I certify the following to be true:

1. The collection is 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: Tresa Young, Management Program Analyst, ACF Children’s Bureau­­____

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 [X] 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 hours per Response	Annual Burden
Title IV-E Agencies	55	1	24	1320
Totals				1320

FEDERAL COST: The estimated annual cost to the Federal Government is $11,847.

TYPE OF COLLECTION:

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

[ ] Web-based

[X] 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: 0970-0558, Expiration Date: 11/23/2023.

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 0970-0558 and the expiration date is 11/30/2023. 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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