Generic Clearance Form National Champions

0925-0701_GC Form_National Champions Tracking and Feedback Form_Govt.doc

Generic Clearance to Support the Safe to Sleep Campaign at the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD)

Generic Clearance Form National Champions

OMB: 0925-0701

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SUBMISSION OF INFORMATION COLLECTION UNDER THE

SAFE TO SLEEP GENERIC CLEARANCE



DATE OF REQUEST: October 10, 2014


SUB AGENCY (I/C): NICHD


TITLE: Safe to Sleep National Champions Tracking and Feedback Form


GENERIC CLEARANCE UNDER OMB#: 0925-0701 EXP. DATE: 07/31/2017


ABSTRACT:

The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) propose conducting an assessment of its Safe to Sleep® (STS) National Champions (NC) program. NC is a volunteer program designed to enlist interested members of the general public and health care professionals in conducting local media outreach activities (in print, radio, television, and social media), and community outreach activities on behalf of the STS campaign.


NICHD will collect information using the STS NC Tracking and Feedback form (Attachment 3). The form collects information on the types of media hits and media outlets Champions have been able to contact and the target audiences of these various outlets, as well as types of community outreach activities conducted. This information will be used to track the Champions’ activities and the total number of people reached. Champions will also be asked to comment on any challenges they faced, lessons learned, as well as accomplishments. This information will be used to identify areas where additional guidance is needed from NICHD and to adjust training activities to improve the program’s overall usefulness and effectiveness.


TOTAL ANNUAL BURDEN APPROVED: 3,000

BURDEN USED TO DATE: 0

BURDEN THIS REQUEST: 125 State/local/tribal governments


FEDERAL COST: The estimated annual cost to the Federal government is $4,203.44.


IS RACE AND ETHNICITY DATA COLLECTED AS REQUIRED?

______YES ___X___ NO ______ N/A


OBLIGATION TO RESPOND:

___X___ VOLUNTARY

______ REQUIRED TO OBTAIN OR RETAIN BENEFITS

______ MANDATORY


HOW WILL THIS SURVEY BE OFFERED?

__X__WEBSITE

_____ TELEPHONE INTERVIEW

_____ MAIL RESPONSE

_____ IN PERSON INTERVIEW

_____ OTHER: __ ___________


CONTACT INFORMATION:

NAME: Shavon Artis

TELEPHONE NUMBER: 301-435-3459

EMAIL ADDRESS: [email protected]

File Typeapplication/msword
File TitleGeneric Clearance Form - 04/28/2008
SubjectGeneric Clearance Form - 04/28/2008
AuthorOD/USER
Last Modified ByCurrie, Mikia (NIH/OD) [E]
File Modified2014-12-09
File Created2014-12-09

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