Application for GenIC Approval

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-0919)

TITLE OF INFORMATION COLLECTION:

Materials Testing to Develop and Enhance Recruitment Material for the Study to Explore Early Development (SEED) - Phase Two

PURPOSE:

As part of evaluating new outreach and recruitment strategies for the second phase of the Study to Explore Early Development (SEED), the Developmental Disabilities branch, National Center on Birth Defects and Developmental Disabilities, is planning to conduct informal focus groups with parents to collect opinions and impressions of our newly developed outreach materials. The intended outcome is for the Developmental Disabilities branch to evaluate new SEED outreach materials and identify areas for improvement. The ultimate goal is to improve the participation and completion rates of the second phase of SEED.

DESCRIPTION OF RESPONDENTS:

The targeted respondents will be attendees of the Autism Society Annual Conference who are between the ages of 18 and 75 and who are the parents of young children (ages 3-6 years). The Autism Society Annual Conference is scheduled to take place in San Diego, California, on July 25 – 28, 2012. Only English speaking respondents will be selected. There will be three focus groups with 10 volunteer participants per group. Announcements about the focus groups will be made after select conference sessions and a number of flyers will be posted in common areas. The announcements and flyers will include the time and place that each focus group will take place as well as contact information to learn more about the focus groups. When parents come to the focus groups we will confirm if they are a parent of a young child age 3-6. There are no other eligibility criteria. The first 10 volunteers who arrive at the designated time and place for each focus group will be those who are chosen to participate. Any volunteers who arrive after those first 10 will be notified that the maximum number has been reached, invited to participate in the next focus group, and/or thanked for their interest. All participants will be assured that their participation is voluntary.

TYPE OF COLLECTION: (Check one)

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

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

[X] 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: ___Julia Richardson_______________________________________

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? N/A

3. If Applicable, has a System or Records Notice been published? N/A

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
English speaking Individuals or Households (aged 18 -75 with young children aged 3-6)	30	1	30
Totals	30	1	30

FEDERAL COST: The estimated annual cost to the Federal government is ___$2,356_________

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? [ ] Yes [X] 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?

Participants will comprise a convenience sample from the attendees of the Autism Society Annual Conference, scheduled to take place in San Diego, California, on July 25 – 28, 2012, who are between the ages of 18-75 and who have young children age 3-6. Only English speaking participants will be selected. Announcements about the focus groups will be made after select conference sessions and a number of flyers will be posted in common areas. The announcements and flyers will include the time and place that each focus group will take place as well as contact information to learn more about the focus groups. When parents come to the focus groups we will confirm if they are a parent of a young child age 3-6. There are no other eligibility criteria. The first 10 volunteers who arrive at the designated time and place for each focus group will be those who are chosen to participate. Any volunteers who arrive after those first 10 will be notified that the maximum number has been reached, invited to participate in the next focus group, and/or thanked for their interest. All participants will be assured that their participation is voluntary.

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? [ X ] Yes [ ] No

Please make sure that all instruments, instructions, and scripts are submitted with the request.

Focus Group Moderator Guide and copies of materials to be evaluated are attached.

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

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.

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

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: Provide answers to the questions.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

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 governments; or (4) Federal Government. Only one type of respondent can be selected.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

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

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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