Supporting Documentation

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0990-0379)

T ITLE OF INFORMATION COLLECTION:

Comment card for soliciting feedback on “A Public Health Response to Trauma: Creating Conditions, Connection and Community for Women and Families” curriculum.

PURPOSE: To collect feedback from program participants on the HHS Office on Women’s Health (OWH) training curriculum “A Public Health Response to Trauma: Creating Conditions, Connections and Community for Women and Families.” The curriculum will be delivered in person to community based and faith based agency staff and former and current consumers of services at three US sites across the country. The purpose of the training curriculum is: (1) to increase the knowledge base and skills of service providers and program participants in the area of trauma-informed practice; (2) to increase the capacity of providers and program participants from diverse sectors to adopt trauma-informed practice; and (3) to develop a community of trauma-informed providers and program participants across the country. The results will be used to make any needed revisions to the training curriculum.

DESCRIPTION OF RESPONDENTS:

People who have completed the curriculum at three US sites, including among others, community-based and faith-based agency administrators, supervisors, program directors, practitioners and front-line workers. There are four training modules in the curriculum. The comment card will be administered and collected at the end of each training module.

TYPE OF COLLECTION: (Check one)

[ X] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[] Focus Group [ ] Other: ______________________

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:_Sandra Bennett-Pagan, LCSW, Regional Women’s Health Coordinator, HHS Office on Women’s Health Region II and Ledia Martinez, MD, MPH , Regional Liaison, HHS Office on Women’s Health

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [X ] No

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ X ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [ X ] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time (hours)	Burden (hours)
Individual program participants	60	40/60	40
Totals	60	40/60	40

FEDERAL COST: The estimated annual cost to the Federal government is $23,139.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [X ] Yes [ ] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

HHS Office on Women’s Health Regional Coordinators will make recommendations on which location in their region to consider for piloting the training curriculum. After reviewing the recommendations, the Project Officers, in consultation with the training curriculum contractors, will identify 3 sites across the US to participate in the pilot testing of the curriculum. A total of sixty participants will participate in the pilot testing of the curriculum. All sixty participants will be asked to complete a comment card at the end of each of the four training modules.

Are you sampling or doing a census (providing every participant a card)?

We are doing a census. We are providing every participant a comment card for data collection at the end of each of the four training modules.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ x] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [ x ] No

Expiration Date: 7/31/2014

# # #

3