Generic Program Progress Performance Reports Submission Template

Request for Approval under the “Generic Clearance for Program Progress Performance Reports” (OMB Control Number: 0690-NEW)

TITLE OF INFORMATION COLLECTION:

PURPOSE:

DESCRIPTION OF RESPONDENTS: (e.g. states or type respondents)

TYPE OF COLLECTION:

[ ] Grant – Progress Report

[ ] Cooperative agreement – Progress Report

[ ] Other: ____________________________________________

Administration of the Instrument

1. How will the information collected be submitted to the agency? (Check all that apply)

[ ] Grants.gov

[ ] Web-based

[ ] Email

[ ] Mail

[ ] Other:_______________________

CERTIFICATION:

I certify the following to be true:

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

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

Name: ________________________________________________

To assist in the 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 Respondent	No. of Respondents	Participation Time	Burden Hours
Totals

FEDERAL COST: The estimated annual cost to the Federal government is ________________

Required Additional Information

1. Line of Business:

2. Subfunction:

3. Privacy Act System of Records:

4. Federal Registration citation information:

5. Number of respondents for small entities:

6. Percentage of respondents reporting electronically:

All required instruments, instructions, correspondences (emails, letters, etc.) to respondents, and scripts as separate documents must be submitted along with this request document.

Every instrument must have the following displayed – OMB Control No. 0690-NEW

• Expiration Date: XX/XX/XXXX;

• All Performance Progress Report (PPR) instruments must display the following required PRA Burden Statement. The following PRA Burden Statement template can be used. Replace highlighted areas with content specific to your collection. 

PAPERWORK REDUCTION ACT (PRA) OF 1995 (Public Law 104-13) STATEMENT OF PUBLIC BURDEN: 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 unless that collection of information displays a currently valid OMB Control Number (enter OMB Control Number). Public reporting burden for this report is estimated to average ? hours/minutes per response. This burden includes time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to the Title, Bureau of ____________, Street Address., City, State and Zip Code.

Instructions for completing Request for Approval under the “Generic Program Progress Performance Reports” (OMB Control Number: 0690-NEW)

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

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.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

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

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Must submit all instruments, instructions, and scripts with the request.

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