Generic Customer Survey Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 1800-0011)

TITLE OF INFORMATION COLLECTION: U.S. Department of Education Reform Support Network TA Expert Consultants Assessment (2013)

PURPOSE: The U.S. Department of Education (ED) is committed to understanding the utility and relevance of TA provided to Race to the Top (RTT) States through the Reform Support Network (RSN) in order to inform both service and program improvement in ensuring States achieve their Race to the Top goals as authorized by the American Recovery and Reinvestment Act of 2009 (ARRA), Section 14005-6, Title XIV, (Public Law 111-5). The Reform Support Network provides TA to Race to the Top States through a variety of mechanisms including Communities of Practice, Webinars, Convenings, Product Development, and individualized technical assistance.

In support of RTT States, it is important to ensure that all TA provided through RSN is of high quality, relevant, useful, and helpful as States work towards achievement of their RTT goals. A survey will be administered to subject-matter experts who are informing future TA efforts and results used to inform future TA and better understand how and when TA planning is useful to RTT grantees from the experts’ perspective.

This attached TA feedback form is designed to be tailored slightly to fit the mode and objectives for each of the estimated 12 TA expert planning events that occur annually while collecting similar data across all events that can be used to identify trends for continuous service and program improvement.

DESCRIPTION OF RESPONDENTS: Respondents will include education reform expert consultants from a variety of private sector and non-profit education-based organizations who can inform content development for RSN TA activities. Surveys will be handed out to participants in-person at face-to-face TA planning meetings and electronically for expert planning meetings that occur over the phone or on the internet.

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:__Jamila Smith _____________________________________________

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
Education Reform Expert Consultants for Race to the Top Initiatives	120	5 minutes	10 hours
Totals	120	5 minutes	10 hours

FEDERAL COST: The estimated annual cost to the Federal government is _$3,587.15_

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?

All participants in TA expert planning activities will be invited and eligible to respond. TA experts are carefully selected to participate in each planning meeting from an expert database. The database consists of expert consultants recommended by ED or recruited through an RFP who specialize in key areas of education reform such as teacher preparation and licensure, teacher/principal professional development design and delivery, communication and outreach, and data systems. All participants who have attended these planning meetings will receive an invitation to provide feedback.

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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