CCWIS Template Submission Form

Request for Approval under the clearance of the “Generic CCWIS Review & Technical Assistance” Office of Management and Budget (OMB) Control Number: 0970-0568

TITLE OF INFORMATION COLLECTION: Comprehensive Child Welfare Information System (CCWIS) Review and Technical Assistance Process Self-Assessment Tool: Data Exchange Self-Assessment Tool

PURPOSE: The Data Exchange Self-Assessment Tool submitted under this overarching generic clearance will be used by the Children’s Bureau to:

• Proactively identify risks, system shortcomings, or deficiencies in system planning, design, and/or implementation;

• Identify gaps and determine strategies for improvement or corrective action, or to allow a project course change; and,

• Identify the need for additional technical assistance or further federal guidance.

The specific self-assessment tools submitted as part of this generic information collection request is described in the following table:

Topic	Purpose/Use
Data Exchange Functions	This tool will help agencies assess compliance with CCWIS requirements regarding exchanges, exchange standards, and the effectiveness of data-sharing practices in strengthening program integrity and supporting improved outcomes for children and families.

DESCRIPTION OF RESPONDENTS: States and tribes receiving title IV-E funding for a CCWIS.

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: Tresa Young, Director, Division of State Systems, ACF Children’s Bureau­­____

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 [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 been published? [ ] Yes [ ] No

BURDEN HOURS

Information Collection	Category of Respondent	No. of Respondents	No. of Responses per Respondent per year	Burden hours per Response	Annual Burden
Data Exchange Self-Assessment Tool	Title IV-E Agencies	55	1	10	550
Total					550

FEDERAL COST: The estimated annual cost to the Federal Government is $11,847.

TYPE OF COLLECTION:

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

[ ] Web-based

[X] E-mail

[ ] Paper mail

[ ] Other, Explain

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

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