Request for Approval

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

TITLE OF INFORMATION COLLECTION: DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators

PURPOSE:

The Division of Human Development and Disability (DHDD) will conduct a series of surveys to obtain feedback on the satisfaction of technical assistance received by state Disability and Health Coordinators and National Public Health Practice and Resource Centers (PHPRCs) representatives as part of a larger Continuous Quality Improvement Initiative. The surveys are designed to be easy to use and easy to access.

The feedback received from the state Disability and Health Coordinators and PHPRCs representatives will allow us to improve our technical assistance, conference calls, site visits, SharePoint site, monitoring tools and services.

DESCRIPTION OF RESPONDENTS:

The respondents are disability and health representatives/coordinators from the 18 funded states (Alabama, Florida, South Carolina, North Carolina, Arkansas, New Hampshire, New York, Massachusetts, New York, Rhode Island, Alaska, Oregon, Montana, North Dakota, Iowa, Ohio, Michigan and Delaware) and PHPRCs’ Christopher and Dana Reeve Foundation, Amputee Coalition of America, National Center on Health and Physical Activity and Disability, Special Olympics and The Arc. There will be approximately 2 respondents per state and PHPRC.

A series of 11 surveys will be administered via Survey Monkey. A link to the survey will be embedded in an email to all state Disability and Health Coordinators and PHPRC representatives. Surveys will be administered once and not all surveys will be completed by all respondents. The surveys will be deployed at different times based on the nature of the survey.

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:_Monique Young ([email protected])

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

TOTAL BURDEN HOURS

A series of 11 web surveys will be conducted to obtain feedback on the satisfaction of technical assistance received by state Disability and Health Coordinators and National Public Health Practice and Resource Centers (PHPRCs) representatives as part of a larger Continuous Quality Improvement Initiative. Surveys will be administered once and not all surveys will be completed by all respondents. The surveys will be deployed at different times based on the nature of the survey. The estimated burden for all 11 surveys is 85 hours. There is no cost to respondents other than their time.

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
State Disability and Health Coordinators/PHPRC Representatives (Annual Grantee Meeting Idea Generation Survey)	46	15/60	12
State Disability and Health Coordinators/PHPRC Representatives (Electronic IPR Feedback Survey)	46	15/60	12
State Disability and Health Coordinators/PHPRC Representatives (Monthly Conference Call Evaluation Survey)	46	10/60	8
State Disability and Health Coordinators/PHPRC Representatives (Electronic Workplan Feedback Survey)	46	15/60	12
PHPRC Representatives (RETT Group Conference Call Survey)	10	5/60	1
State Disability and Health Coordinators (SETT Group Conference Call Survey)	36	5/60	3
State Disability and Health Coordinators (SETT Group Feedback Survey)	36	10/60	6
PHPRC Representatives (RETT Group Feedback Survey)	10	10/60	2
State Disability and Health Coordinators/PHPRC Representatives (Post Evaluation Webinar Survey)	46	10/60	8
State Disability and Health Coordinators (Disability and Health Intervention/Programs Survey)	36	15/60	9
State Disability and Health Coordinators/PHPRC Representatives (Disability and Health Branch (DHB) Site Visit Evaluation)	46	15/60	12
TOTALS	404		85

FEDERAL COST: The estimated annual cost to the Federal government is federal employee/contractor staff time and state and PHPRC staff time. The approximately cost for all proposed surveys is $3,042.

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?

Each DHDD funded partner will be surveyed. These include Disability and Health representatives from the following 18 states: Alabama, Florida, South Carolina, North Carolina, Arkansas, New Hampshire, New York, Massachusetts, New York, Rhode Island, Alaska, Oregon, Montana, North Dakota, Iowa, Ohio, Michigan and Delaware; and PHPRCs: Christopher and Dana Reeve Foundation, Amputee Coalition of America, National Center on Health and Physical Activity and Disability, Special Olympics and The Arc. There will be approximately 2 respondents per state and PHPRC.

A series of 11 surveys will be administered via Survey Monkey to obtain feedback on the satisfaction of technical assistance received by state Disability and Health Coordinators and National Public Health Practice and Resource Centers (PHPRCs) representatives as part of a larger Continuous Quality Improvement Initiative. A link to the survey will be embedded in an email to all state Disability and Health Coordinators and PHPRC representatives. Not all surveys will be completed by all respondents. The surveys will be deployed at different times based on the nature of the survey.

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

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

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

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