Generic Clearnce Form

SUBMISSION OF INFORMATION COLLECTION UNDER THE

SAFE TO SLEEP GENERIC CLEARANCE

DATE OF REQUEST:

SUB AGENCY (I/C): NICHD

TITLE:

GENERIC CLEARANCE UNDER OMB#: 0925-XXXX EXP. DATE: xx/xx/20xx

ABSTRACT:

Briefly describe the information collection including background, purpose, why it is needed, how information will be used, type of participants, methodology and research instrument form.

This form should be no more than 1 page.

TOTAL ANNUAL BURDEN APPROVED:

BURDEN USED TO DATE:

BURDEN THIS REQUEST:

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

IS RACE AND ETHNICITY DATA COLLECTED AS REQUIRED?

______YES ______ NO ______ N/A

OBLIGATION TO RESPOND:

______ VOLUNTARY

______ REQUIRED TO OBTAIN OR RETAIN BENEFITS

______ MANDATORY

HOW WILL THIS SURVEY BE OFFERED?

_____ WEB SITE

_____ TELEPHONE INTERVIEW

_____ MAIL RESPONSE

_____ IN PERSON INTERVIEW

_____ OTHER: ___________________________________

CONTACT INFORMATION:

NAME: ___________________________________________

TELEPHONE NUMBER: ____________________________

EMAIL ADDRESS: _________________________________