Attachment A - ACF Meeting Registration GenIC Submission Form

Request for Approval under the “Administration for Children and Families Generic for Information Collections Related to Gatherings”

(OMB Control Number: 0970-0XXX)

TITLE OF INFORMATION COLLECTION:

PURPOSE:

DESCRIPTION OF RESPONDENTS:

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 information collected is not intended to be disseminated to the public¹.

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

Name and affiliation:________________________________________________

To assist review, please provide the following information:

BURDEN HOURS

Instrument Title	Category of Respondent	No. of Respondents	Participation Time	Burden
Totals

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 or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

Instructions for completing Request for Approval under the “Generic For Reviewer Recruitment”

FORM AND INSTRUCTIONS

• All instruments must display the following required PRA information:

  • OMB Control Number: 0970-0XXX

Expiration date: XX/XX/20XX

• The following PRA Burden Statement. The following template can be used. 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 collection of information is voluntary. 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 0970-0XXX and the expiration date is XX/XX/20XX. If you have any comments on this collection of information, please contact….

SUBMISSION FORM

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. These groups must have experience with the program.

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 (PII): 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 Government; 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 (in minutes) required for a response

Burden: Provide the burden hours by multiplying: (# of respondents) x (# or responses) x (burden per response).

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

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

Submit all instruments, instructions, and scripts with the request.

1 The information collected through this request is primarily for internal review and will not be published. However, for certain activities information submitted by accepted participants, such as research abstracts to be presented in a poster session, may be published on an ACF website or included in a printed or online program for the activity or subsequent publication describing the activity.

5