GenIC Request Template

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Attachment 3: GenIC Request Template 
OMB Control Number 0920-1282 
Performance Measures Project 
Request for GenIC Approval (for data collection in 20XX, 20XX, 20XX) 
 
Date: 
 
CIO: 
PROJECT TITLE:  
PURPOSE AND USE OF COLLECTION: 
NUMBER AND TITLE OF NOFO: 
NUMBER OF PARTICIPATING RECIPIENTS: 
ESTIMATED ANNUAL FUNDING: 
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. 

See example 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: 
 
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 
 
TABLE COMPLETION INSTRUCTIONS
ANNUALIZED BURDEN HOURS  
Type of Respondent  
Form Name 
No. of Respondents 
No. of Responses per Respondent 
Avg. Burden Per Response 
Total Burden (in Hours) 
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.  
Provide the title of the information collection form. 
Provide an estimate of the Number of respondents i.e., the number of recipients that will complete the form.
The number of times a respondent will complete the form in one year (1= annual; 2=semi-annual; 4=quarterly; 12-monthly). 
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. 

Example: Enter “10” to signify “10 hours”.  
Multiply straight across the row and round to the nearest integer. 






Totals 
 
 
 
 

 
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 
List (specify) the years in which data will be collected. 

20XX, 20XX, 20XX
Enter the number of years (1, 2, or 3).
Enter the Total Annualized Burden Hours from the preceding table
Multiply the Number of Years times the Annualized Burden Hours. 


EXAMPLE TABLE
 
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 
2026,2027 
2 
1,450 
2,900