Attachment A_Fast track memo template_one time funding

Request for Approval under the “Applications for and Monitoring of New, One-Time Funding Programs Administered by the Health Resources and Services Administration” (OMB Control Number: 0906-XXXX)

TITLE OF INFORMATION COLLECTION:

PURPOSE:

DESCRIPTION OF RESPONDENTS:

TYPE OF COLLECTION: (Check one)

[ ] One-Time Grant Application [ ] Program Monitoring/Progress Reports

[ ] One-Time Cooperative Agreement Application [ ] Other

[ ] One-Time Pilot Program Application

HOW WILL INFORMATION COLLECTED BE SUBMITTED TO THE AGENCY?

[ ] Grants.gov

[ ] Other:_______________________

TYPE OF FUNDING ANNOUNCEMENT: (Check all that apply)

[ ] Notice of Funding of Opportunity (NOFO)

[ ] Grants.gov Announcement

[ ] Funding Opportunity Announcement (FOA)

[ ] Request for Application (RFA)

[ ] Notice of Funding of Announcement (NOFA) (Announced in the Federal Register)

[ ] Notice of Solicitation of Application (NOSA)

[ ] Notice of Awards

[ ] Not Applicable

[ ] Other Funding Announcement Types: __________________________________

CERTIFICATION:

I certify the following to be true:

1. This collection is associated with an application or program monitoring for HRSA-funded programs that provide one-time funding.

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. The results are not intended to be disseminated to the public.

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

Name:

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

Statutory Authority

What is the statutory authority for this program?

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

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden Hours Total
Totals

FEDERAL COST:

The estimated annual cost to the federal government is $X, which includes [provide a brief description of the costs to the government, including the number of staff hours and the GS level of those who would be working on it, i.e., “$800 (12 hours at the GS-14 level) in project management and oversight.” The GS rate should be multiplied by 1.5 to account for overhead costs.]

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