GenIC Request Template (Project Description and Justification)

OMB Control Number 0920-1282

Performance Measures Project

Request for genIC Approval (for data collection in 2023, 2024, 2025)

CIO:

PROJECT TITLE:

PURPOSE AND USE OF COLLECTION:

NUMBER AND TITLE OF NOFO:

NUMBER OF PARTICIPATING RECIPIENTS:

DESCRIPTION OF NOFO (check all that apply):

__ Funds all 50 states

__ Has budget higher than $10 million per year

__ Has significant stakeholder interest (e.g. partners, Congress)

Please elaborate:

PERFORMANCE METRICS USED & JUSTIFICATIONS:

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; it is not intended to be used as the principal basis for policy decisions

Name: ________________________________________________

To assist review, please answer the following questions:

ANNUALIZED BURDEN HOURS

This table calculates the total estimated burden per year for all recipients.

Type of Respondent	Form Name	No. of Respondents	No. of Responses per Respondent	Avg. Burden Per Response	Total Annualized Burden Hours
Totals

TOTAL BURDEN HOURS FOR THIS GENIC

This table specifies the calendar years in which information will be collected and calculates the total burden hours requested over the approved timeframe of the generic.

Data Collection Timeframe (List up to 3 Years)	No. Years Requested	Annualized Burden Hours	Total Burden Hours for this GENIC

See examples provided with this template.

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

Administration of the Instrument

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

[ ] Web-based

[ ] Email

[ ] Postal Mail

[ ] Other, Explain

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

Instructions for completing genIC Request for Approval for

Performance Measurements Project*

Project Title: Provide the name of the collection that is requested.

PURPOSE AND USE OF COLLECTION: 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.

NUMBER AND TITLE OF NOFO: Provide federal grant or other identifying number and title

NUMBER OF PARTICIPATING RECIPIENTS: Enter number of recipient organizations

DESCRIPTION OF NOFO: Briefly describe the key programmatic activities and the targeted group/groups for this collection.

PERFORMANCE METRICS USED & JUSTIFICATIONS: Describe the changes to the sample forms and justifications for metrics selected

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

COMPLETING THE TABLE: ANNUALIZED RESPONSES AND 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; (4) Federal Government or Non-Governmental Organizations. Only one type of respondent can be selected.

Form Name: Provide the title of the information collection form.

No. of Respondents: Provide an estimate of the Number of respondents i.e., the number of recipients that will complete the form.

Burden per Response: Provide an estimate of the amount of time required for a respondent to complete the form one time. If burden can be expressed in whole hours, enter an integer value. If burden can not be expressed in whole hours, express as minutes using the following notation: “[xx] / 60”.

Example: Enter “10” to signify “10 hours”.

Enter “320/60” to signify “320 minutes” which is equivalent to “5 hours and 20 minutes.”

Number of Responses per Respondent: The number of times a respondent will complete the form in one year (1= annual; 2=semi-annual; 4=quarterly; 12-monthly).

Total (Annualized) Burden Hours: Multiply straight across the row and round to the nearest integer.

COMPLETING THE TABLE: TOTAL BURDEN FOR THIS GENIC

Data Collection Timeframe: List (specify) the years in which data will be collected.

Number of Years: Enter the number of years (1, 2, or 3).

Annualized Burden Hours: Enter the Total Annualized Burden Hours from the preceding table.

Total Burden Hours for this GENIC: Multiply the Number of Years times the Annualized Burden Hours.

FEDERAL COST: Estimate the annual cost to the Federal government for this collection.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked.

*Note to applicants- please delete the instructions page upon completion of this template

EXAMPLE 1

ANNUALIZED BURDEN HOURS

Type of Respondent	Form Name	No. of Respondents	No. of Responses per Respondent	Avg. Burden Per Response	Total Burden (in Hours)
States	Standard Annual Reporting Form for CAT A and CAT B	50	1	30	1,500
States	Supplemental Form for CAT B Recipients	10	1	2	20
Totals					1,520

TOTAL BURDEN HOURS FOR THIS GENIC

Data Collection Timeframe (List up to 3 Years)	No. Years Requested	Annualized Burden Hours	Total Burden Hours for this GENIC
2023, 2024, 2025	3	1,520	4,560

EXAMPLE 2

ANNUALIZED BURDEN HOURS

Type of Respondent	Form Name	No. of Respondents	No. of Responses per Respondent	Avg. Burden Per Response	Total Burden (in Hours)
States	Standard Annual Reporting Form	50	1	25	1,250
States	Quarterly Report	50	4	1	200
Totals					1,450

TOTAL BURDEN HOURS FOR THIS GENIC

Data Collection Timeframe (List up to 3 Years)	No. Years Requested	Annualized Burden Hours	Total Burden Hours for this GENIC
2024, 2025	2	1,450	2,900

EXAMPLE 3

ANNUALIZED BURDEN HOURS

Type of Respondent	Form Name	No. of Respondents	No. of Responses per Respondent	Avg. Burden Per Response	Total Burden (in Hours)
States	Performance Monitoring Report	30	1	615/60	308
Totals					308

TOTAL BURDEN HOURS FOR THIS GENIC

Data Collection Timeframe (List up to 3 Years)	No. Years Requested	Annualized Burden Hours	Total Burden Hours for this GENIC
2025	1	308	308

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