ACF Reviewer Recruitment Submission Form

Request for Approval under the “Generic Clearance for Reviewer Recruitment” (OMB Control Number: 0970-0477)

TITLE OF INFORMATION COLLECTION:

PURPOSE:

DESCRIPTION OF RESPONDENTS:

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.

Name:________________________________________________

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

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Totals

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

Administration of the Instrument

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

[] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] 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 For Reviewer Recruitment”“Generic

FORM AND INSTRUCTIONS

• All instruments must display the following required PRA information:

  • OMB Control Number: 0970-0477

Expiration date: 04/30/2022

• 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: The OMB # is 0970-0An 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. ). cite authorityThis collection of information is required to retain a benefit ( hours per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. XX Public reporting burden for this collection of information is estimated to average .]….[Through this information collection, ACF is gathering information to….]/[The purpose of this information collection is to477 and the expiration date is 04/30/2022. . …If you have any comments on this collection of information, please contact

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): , and they should only retain PII for the period of time that is necessary to achieve a specific objective.necessaryProvide answers to the questions. Note: Agencies should only collect PII to the extent

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 Provide an estimate of the number of respondents. of Respondents:.

No. of Responses per Respondent: .per yearProvide the number of responses per respondent

Burden per Response: Provide an estimate of the amount of time (in minutes) required for a response

Burden:hours by multiplying: (# of respondents) x (# or responses) x (burden per response).burden Provide the

FEDERAL COST: Provide an estimate of the annual cost to the federal government.

TYPE OF COLLECTION: If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.all that apply. Check

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

5