Center for States General Assessment for Tailored Services

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

T ITLE OF INFORMATION COLLECTION:

Center for States General Assessment for Tailored Services

PURPOSE:

This is a request for approval by the Office of Management and Budget (OMB), under the Federal Paperwork Reduction Act of 1995, for a new data collection task to be added to the Administration for Children and Families’ already approved generic OMB clearance # 0970-0401. The proposed information collection activity includes onsite interviews assessing strengths and concerns within each State that may inform the development, implementation, and modification of the services provided by the Capacity Building Collaborative. The Capacity Building Collaborative involves three centers funded by the Children’s Bureau to serve as a focal point for national child welfare expertise and evidence-informed training and technical assistance services for State and Territorial public child welfare agencies, Tribes and Tribal organizations, and legal and judicial partners of the child welfare system. The data collection will take place primarily on-site at the state/territory agency and include interviews with multiple agency representatives (phone interviews will also be conducted on an as needed basis). It is expected that the Center for States team will also connect with the State by phone so that the representatives can prepare for and gather appropriate documents from which to pull information to then participate in the interviews. This time is included in the burden estimate.

DESCRIPTION OF RESPONDENTS:

Assessment participants will include child welfare agency staff from 52 States/territories who can respond to the domains addressed in the assessment protocol through verbal responses and pulling information from existing state documentation. It is expected that an average of five staff from each state would be involved in the onsite assessment and could include representatives from the following: Child Welfare Leadership (designees to be determined by Child Welfare Director); Budget/ Finance staff; Data staff; Policy/QA/QI staff; Human Resources/Staff Development staff; or others as determined by the Child Welfare Director based on the specifics of the jurisdiction.

An estimate of the annual response burden is outlined in the following table.

TYPE OF COLLECTION: (Check one)

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

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

[ ] Focus Group [X] Other: Interview_____

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: ______Brian Deakins_________________________________________

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 (Hours)	Burden (Hours)
Federal/State/local governments	260	6.4	1664
Totals			1664

FEDERAL COST: The estimated annual cost to the Federal government is: $188,554.08

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?

Center for States staff will work with the Child Welfare Leadership in each State/Territory to determine who is most appropriate to participate in the assessment given the domains of interest. It is expected that a representative from the following areas will contribute to the assessment interview: Child Welfare Leadership (designees to be determined by Child Welfare Director); Budget/ Finance staff; Data staff; Policy/QA/QI staff; Human Resources/Staff Development staff; or others as determined by the Child Welfare Director based on the specifics of the jurisdiction.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[] Web-based or other forms of Social Media

[X] 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.

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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