Generic Clearance Form National Champions

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 for Individuals or Households

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]