Justification for survey

To assist review, please provide answers to the following questions:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [X ] No
2. If Yes, is the information that will be collected included in records that are subject to the
Privacy Act of 1974? [ ] Yes [ ] No N/A
3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No N/A
Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to
participants? [ ] Yes [ X] No (If yes, please explain.)
BURDEN HOURS
Category of Respondents

No. of Respondents

GWCA sponsored program participants

150

Totals

Participa Burden
tion
Time
10 mins
25 hours
25 hours

FEDERAL COST: The estimated annual cost to the Federal government is _$500___
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 [X]
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.
The respondents will be selected among the community programs participants. All participants
who are at least 16 years old will be invited to participate.

Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[ ] Web-based or other forms of Social Media
[ ] Telephone
[X] In-person
[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [X] Yes [ ] No
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Please make sure that all instruments, instructions, and scripts are submitted with the
request.

INSTRUCTIONS
TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the
subject of the request. (e.g., Comment card for soliciting feedback on xxxx)
PURPOSE: 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.
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.
TYPE OF COLLECTION: Check one box. If you are requesting approval of other
instruments under the generic, you must complete a form for each instrument.
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: Provide answers to the questions.
Gifts or Payments: If you answer yes to the question, please describe the incentive and provide
a justification for the amount.
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; or (4) Federal Government. Only one type of respondent can be selected.
No. of Respondents: Provide an estimate of the Number of respondents.
Participation Time: Provide an estimate of the amount of time required for a respondent to
participate (e.g., fill out a survey or participate in a focus group)
Burden: Provide the Annual burden hours: Multiply the Number of responses and the
participation time in minutes and divide by 60.
FEDERAL COST: Provide an estimate of the annual cost to the Federal government.
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. Please provide a description of how you plan to
identify your potential group of respondents and how you will select them. If the answer is yes,
to the first question, you may provide the sampling plan in an attachment.

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Administration of the Instrument: Identify how the information will be collected. More than
one box may be checked. Indicate whether there will be interviewers (e.g., for surveys) or
facilitators (e.g., for focus groups) used.
Please make sure that all instruments, instructions, and scripts are submitted with the
request.

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