Attachment A - Submission Template for PPR Gen IC (0970-0490)

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

TITLE 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 in compliance with HHS regulations.

2. The collection is non-controversial and does not raise issues of concern to other federal agencies.

3. Information gathered is meant primarily for program improvement and accountability.

Name and Title:________________________________________________

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”

FORM AND INSTRUCTIONS

• All PPR instruments must display the following required PRA information:

  • OMB Control Number: 0970-0490

Expiration date: XX/XX/2023

• 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 required to retain a benefit (cite authority). 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. If you have any comments on this collection of information, please contact….

• Please note the following:

  • The PPR should not request sensitive information

  • All grantees must adhere to 45 CFR § 75.303 (e) to take reasonable measures to safeguard protected personally identifiable information of program participants.

• Submit the data collection form as one individual file and the instruction document as one individual file.

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.

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