Form 1 CB Disaster Information Collection Form

Request for Approval under the “Generic Clearance for Disaster Information Collection Form (OMB Control Number: 0970-0476)

T ITLE OF INFORMATION COLLECTION:

Children’s Bureau (CB) Disaster Information Collection Plan

PURPOSE:

The assessment information collected in the Disaster Information Collection Forms on ACF program impacts will be used to provide real time updates during the response and recovery phases of a disaster. The information collected will be on programs within the disaster-affected area, and neighboring areas.

The Disaster Information Collection Forms will be a key source of information on ACF program impact. The assessment will provide information to respond to inquiries about ACF human services response and recovery efforts, specifically for children and families that need the support of ACF programs following a disaster. The collected data will help the ACF programs provide technical assistance and impact-specific subject matter expertise to the State and the impacted grantees.

DESCRIPTION OF RESPONDENTS:

Child welfare agencies, state administrators, and federal staff.

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

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. The results are not intended to be disseminated to the public.

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

6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

7. The information collection does not employ statistical methods.

Name: LCDR Tala Hooban

To assist review, please provide answers to the following question:

Personally Identifiable Information:

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

Category of Respondent	No. of Respondents	Participation Time	Burden
Child welfare agency/state administrator	10	1 hour	10 hours
Totals	10	1 hour	10 hours

FEDERAL COST: The estimated annual cost to the Federal government is $7,612.80

20% at GS-12 rate. GS-12 rate of $39.65x8 hoursx24 weeks = $7,612.80 (total estimated cost)

Administration of the Instrument

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

[x] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[x] Other, Explain

Email of Microsoft Word document.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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