Justification Template

Request for approval under the clearance of the “Generic Performance Progress Report” OMB control Number: 0970-0490

T ITLE OF INFORMATION COLLECTION:

PURPOSE:

DESCRIPTION OF RESPONDENTS: (e.g. States or type of non-profit)

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary and in compliance with HHS regulations.

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.

Name:________________________________________________

To assist OMB review of your request, please provide answers to the following question:

PERSONALLY IDENTIFIABLE INFORMATION:

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

Category of Respondent	No. of Respondents	No. of Responses per Respondent	Burden per Response	Total Burden
Totals

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

TYPE OF COLLECTION:

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

[ ] Web-based

[ ] E-mail

[ ] Paper 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 Performance Progress Report”

Program specific PPRs only need to be submitted to OMB for review and approval.

PPR instruments must display the required PRA information, i.e.,

OMB Control Number: 0970-0490; Expiration date: 1/31/2020 and the following statement:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden for this collection of information is estimated to average ?? hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

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: 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 governments; 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 respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours.

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.

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