ACF Optional-Use Data Sharing Request Form

OMB #: 0970-0531

Expiration Date: 09/30/2025

ACF Optional-Use Data Sharing Request Form

To be completed by ACF (select one):

☐ Approved ☐ Denied ☐ Returned for Modification

Instructions: Fill out the information below and then provide thorough responses to the questions as appropriate to your request.

Primary Contact Name: _________________________________________________­­­­___________

Primary Contact Job Title: __________________________________________________________

Organization or Institution Name: ___________________________________________________

Organization or Institution Address: _________________________________________________

(Provide street address, city, state, zip code)

Primary Contact Phone Number: ____________________________________________________

Primary Contact Email Address: _____________________________________________________

Project Title: ____________________________________________________________________

1. List the names, project roles, organizational/institutional affiliations, and contact information of all individuals that will have access to the data (including external parties such as evaluators or subcontractors).

Response.

2. Provide a description of the overall research project, including the purpose, scope, and rationale for the project. Identify key research or policy questions to be addressed.

Response.

3. Describe why this program data is necessary for your research question. Specifically, explain:

   1. Why the data is needed to answer the research question, and

   2. Why public-use data files cannot meet your research need.

   3. Which data sources you have already reviewed and why they are insufficient to accomplish the project goals.

Response.

4. Will the study be reviewed by an Institutional Review Board (IRB)? Note that ACF does not have an IRB so you must work with an external institution if you choose to obtain approval.

5. What is the scientific and/or policy value of your proposed research? Please review and address aspects of the ACF Strategic Plan and ACF Learning Agenda in your response.

Response.

6. Provide a description of planned analyses to address questions specified in question 3.

7. If you plan to link the data to any other sources:

1. Describe how the linking will help achieve your research objectives.

2. List the other datasets and data fields needed to link to them.

3. Identify any challenges you foresee when trying to accomplish the linkage(s).

Response.

8. How will the results be disseminated and used (e.g., reports, publications, presentations)?

Response.

9. What type of data are you seeking access to?

1. Aggregate (summary) data – go to question 10

2. Case-level (individual) data – go to question 11

Response.

10. Please provide a description of the aggregate data requested, for example:

    1. Variables requested

    2. Cross-tabulations requested

    3. Level of aggregation

    4. Sample to be included (e.g., specific states, demographic groups, etc.)

    5. Years of data to be included

Response.

11. Please provide a description of the case level data requested, for example:

    1. Variables requested

    2. Sample to be included (e.g., specific states, demographic groups, etc.)

    3. Years of data to be included

Response.

12. If personally identifiable information (PII) is requested, please explain why it is necessary and what would not be possible if it were omitted or replaced with non-identifiable unique identifiers.

Response.

13. If you are receiving funding from a federal agency, including ACF/HHS, please list your funding source(s).

Response.

14. What is your requested timeframe for receiving data?

Response.

15. How frequently are you requesting data delivery being requested?

1. One-time or ad hoc

2. Scheduled – indicate how often

Response.

16. How long are you requesting access to this data?

Response.

17. Are you affiliated with a Federal Statistical Research Data Center, or do you have Special Sworn Status?¹

Response.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to facilitate processing of requests for access to ACF Program Office data for research and statistical purposes and to help ACF better understand data sharing requests in aggregate. Public reporting burden for this collection of information is estimated to average 180 minutes per individual, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing and completing the collection of information. This is a voluntary collection of information. 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. All information collected will be kept private to the extent permitted by law. If you have general comments on this collection of information, please contact the ACF Office of Planning, Research and Evaluation, Division of Data and Improvement by email at datagov@acf.hhs.gov. If you have specific questions regarding your data sharing request being made under this form, please contact the ACF Program Office from which you are seeking data.

1 Affiliation with a Federal Statistical Research Data Center or Special Sworn Status are not required. This question is intended to help us ascertain whether someone has previously gone through the process of being approved to use restricted-use data.