ACF DICF GenIC Submission Form

Request for Approval under the “Generic Clearance for Disaster Information Collection Form (OMB Control Number: 0970-0476)

TITLE OF INFORMATION COLLECTION: Administration for Children and Families Disaster Information Collection Form

PURPOSE: The assessment information collected in the Disaster Information Collection Form is used to provide near-real time updates during the response and recovery phases of a disaster. The human and social service information is collected on the programs that fall within the disaster-affected and neighboring areas.

This submission is for a general Disaster Information Collection Form to be used by multiple offices within the Administration for Children and Families (ACF). As with other Disaster Information Collection Forms under this generic, in the event of an emergency, the ACF Office of Human Services Emergency response and Recovery (OHSEPR) reaches out to program offices to determine any impacts on the normal operations of program services. The program offices would then use this form to collect information from programs as necessary. Program offices then provide the information OHSEPR for analysis. OHSEPR provides information back to the ACF program offices following analysis of the collected data.

This information helps the ACF programs to provide technical assistance and impact-specific subject matter expertise to the impacted grantees and state offices. The information gathered in these data collection forms is also used to assess the response and recovery gaps of ACF programs 30 days to one (1) year post disaster.

An analysis of the information received from respondents is reported to the ACF Assistant Secretary and leadership. The Disaster Information Collection Form analysis also serves as a reporting requirement for ACF/OHSEPR. The analysis is shared, as appropriate, with the White House via a brief prepared by FEMA.

DESCRIPTION OF RESPONDENTS: Respondents to the collection form are state administrators, grantees, and subgrantees of ACF programs.

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.

7. The information collection does not employ statistical methods.

Name and Affiliation: ­____Byron Mason, Deputy Director, OHSEPR/ACF___

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [X] 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 (Annual Bases)

Category of Respondent	No. of Respondents	Participation Time	Burden
State administrators, Grantees, Subgrantees,	40	1.5	60 hours
Totals	40	1.5	60 hours

FEDERAL COST: The estimated annual cost to the Federal government is $___2,914.00__

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ X ] Telephone

[ ] In-person

[ ] Mail

[X ] Other, Explain

Via Email

The Disaster Information Collection Form is delivered to grantees/administrator’s respondents via email. Respondents return the form via email. If the impacted respondents are unable to access a computer due to damages from a disaster, ACF Program staff work with the grantees / administrators via the phone to enter the data into the form.

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

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