Generic Template for SSS TA Center Feedback Form

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 1880-0524)

T ITLE OF INFORMATION COLLECTION:

Safe and Supportive Schools Technical Assistance (SSS TA) Center Feedback

PURPOSE:

SSS TA believes that it is important to determine the level of satisfaction of its delivery of technical assistance and supports to grantees and the general public. The data collected regarding the performance and effectiveness of how these technical assistance activities, events and publications are meeting customers’ needs will provide data for the SSS TA overall annual evaluation plan as well as the center’s continuous quality improvement process. As a result, the Department wishes to solicit input from current ED customers and the general public to determine whether they have been satisfied with the services and products provided or whether other services or products would better meet their needs.

DESCRIPTION OF RESPONDENTS:

Audiences vary and are comprised of from 10-150 people. Each will be given the opportunity to score the Feedback Form after each event, presentation or product use. SSS TA Center delivers between 25 to 50 presentations each year to grantees and the general public.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [X] 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 Keenan or Rita Foy-Moss

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, 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 [ ] 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	Burden
Exhibits	1,000	7 mins	117
Publications	10,000	7 mins	1167
Events	1,250	7 mins	146
Totals	12,250	7 mins	1,430

FEDERAL COST: The estimated annual cost to the Federal government is $250,000 covers cost in contract to provide technical assistance activities and website.

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?

The 11 state SSS grantees and their participating school districts are the primary audience; other school districts within those states are the secondary audience; with all other school districts, state agencies and general public are the final audience. We have defined lists for grantees, and districts. Participants from the general public access the center resources through the website which is located on a public domain.

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

[ X] In-person

[ ] Mail

[ ] Other, Explain

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

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