Attachment A - Submission Template for Monitoring Generic

Instructions for completing Request for Approval under the “Generic for ACF Program Office Monitoring Activities”

*NOTE: Please delete the instructions prior to submitting this request.

Monitoring forms approved under this Generic must display the required Paperwork Reduction Act information, which includes the following:

1. On the upper right of the first page: OMB Control Number: 0970-0558, Expiration Date: XX/XX/2026.

2. At the bottom of the first page, include the following language. 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: [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 is a voluntary collection of information.]/[This is a mandatory collection of information (cite authority)]. [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. The OMB # is 0970-0558 and the expiration date is XX/XX/2026. If you have any comments on this collection of information, please contact….

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request.

PURPOSE: Provide a brief background of the grant program and the specific purposes/uses of this proposed data collection.

Following the background information, include the following language, but tailor to your collection to only include bullets that are relevant:

This information collection aligns with the overarching generic for monitoring activities, which specifically states that ACF will collect the information for:

• monitoring of compliance with federal practice, guidelines and requirements,

• quick understanding of and remediation to national, regional, and/or site-specific issues,

• provision of support as needed,

• accurate assessment of the efficiency and efficacy of recipient activities

• documentation of promising practice, innovative services, and program strengths

• flexible and responsive oversight of federal funds

Following the bullets, please tailor the following language to your collection (See A2 of the supporting statement for appropriate uses):

The proposed uses of the data also align with the overarching generic, which specifies that program offices will use information collected under this generic clearance to monitor the efficiency and efficacy of funding recipient activities and to provide support or take appropriate action, as needed.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information.

CERTIFICATION: Please read the certification carefully.

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:

Title of Information Collection: Include a row for each information collection and clearly title to match the name of the form/data collection document

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 required for a respondent to respond to the request (e.g., complete all information requested in a monitoring form).

Burden: Provide the Annual Burden Hours by multiplying # Respondents, # Responses per Respondent, and Burden per Response.

FEDERAL COST: Provide an estimate of the annual cost to the Federal Government. This should include all direct costs to the program office that are related to administering and overseeing this data collection.

TYPE OF COLLECTION: Check all that apply.

Submit all instruments, instructions, and scripts with the request.

Request for Approval under the clearance of the “Generic for ACF Program Office Monitoring Activities” Office of Management and Budget (OMB) Control Number: 0970-0558

TITLE OF INFORMATION COLLECTION:

PURPOSE:

This information collection aligns with the overarching generic for monitoring activities, which specifically states that ACF will collect the information for:

• monitoring of compliance with federal practice, guidelines and requirements,

• quick understanding of and remediation to national, regional, and/or site-specific issues,

• provision of support as needed,

• accurate assessment of the efficiency and efficacy of recipient activities

• documentation of promising practice, innovative services, and program strengths

• flexible and responsive oversight of federal funds

The proposed uses of the data also align with the overarching generic, which specifies that program offices will use information collected under this generic clearance to monitor the efficiency and efficacy of funding recipient activities and to provide support or take appropriate action, as needed.

DESCRIPTION OF RESPONDENTS: (e.g., states, grantees, or type of non-profit)

CERTIFICATION:

I certify the following to be true:

1. The collection is in compliance with U.S. Health and Human Services 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.

4. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

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 been published? [ ] Yes [ ] No

BURDEN HOURS

Title of Information Collection	Category of Respondent	# Respondents (Total)	# Responses per Respondent per year	Burden per Response	Annual Burden

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 to submit all instruments, instructions, and scripts with the request.

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