Proposed Generic Memo_Generic Meeting Registration

Request for Approval under the “Generic Information Collection Request for Health Resources and Services Administration Stakeholder Gatherings” (OMB Control Number: 0906-XXXX)

TITLE OF INFORMATION COLLECTION:

PURPOSE:

DESCRIPTION OF RESPONDENTS:

TYPE OF COLLECTION: (Check one)

[ ] Registration Form/Application Form [ ] Customer Satisfaction Survey

[ ] Customer Comment Card/Complaint Form [ ] Small Discussion Group

[ ] Test of Knowledge [ ] Other:

[ ] Focus Group

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

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.

6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

Name:

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

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.]

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [ ] Yes [ ] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [ ] No

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