Survey Toolkit

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0970-0401)

T ITLE OF INFORMATION COLLECTION:

Feedback survey for the web-based Development, Implementation, and Assessment Toolkit

PURPOSE:

The purpose of the survey is to gather feedback from users of the web-based Development, Implementation, and Assessment Toolkit about the usefulness of the website. This feedback will inform ongoing modifications and improvements to the Toolkit.

DESCRIPTION OF RESPONDENTS:

Current Children’s Bureau (CB) Permanency Innovations Initiative (PII) grantees and other child welfare grantees the Children’s Bureau identifies (if any) who are the target audience for the Development, Implementation, and Assessment Toolkit.

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: Matthew R. McGuire______________________________________

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

3. If Yes, has an up-to-date System of Records Notice (SORN) 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
(3) State, local, or Tribal governments	30	15min	7.5hrs
(2) Private sector	10	15min	2.5hrs
(4) Federal government	0	0min	0hrs
Totals	40	30min	10.0hrs

FEDERAL COST: The estimated annual cost to the Federal government is: $0___________

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?

Potential respondents are grantees that the Children’s Bureau determines should have access to the Toolkit beginning in October 2014. All Toolkit users will be offered the opportunity to complete feedback surveys by clicking a link on the website to access the survey. Completing a survey is voluntary.

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.

The following questions comprise the respective surveys.

Usability of overall website - the link to these questions would be available on the homepage. Users would respond to each item on a seven-point scale ranging from “Strongly Disagree” to “Strongly Agree.” An open field text box would also be available for general comments.

• This website is visually appealing.

• It was easy to move from one page to another.

• The overall organization of the site is easy to understand.

• Individual pages are well designed.

• Terminology used in this website is clear.

• The content of the website met my expectations.

• I would be likely to use this website in the future.

• I was able to complete my tasks in a reasonable amount of time.

• Overall, the website is easy to use.

Utility of each respective section - the link to these questions would be available on the each landing page in the website except the tools, glossary, and annotated bibliography. Users would respond to each item on a seven-point scale ranging from “Strongly Disagree” to “Strongly Agree.” An open field text box would also be available for general comments.

• It was easy to understand the information in this section.

• The information in this section was useful.

• There was useful information in this section beyond what I was looking for.

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. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

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 per row.

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

Participation Time: Provide an estimate of the amount of time (in minutes) 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 Respondents and the Participation Time then 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.

Submit all instruments, instructions, and scripts are submitted with the request.

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