Request for Approval

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-1009)

TITLE OF INFORMATION COLLECTION:

Customer feedback interviews of state-level traumatic brain injury prevention workers.

PURPOSE:

The National Center for Injury Prevention and Control (NCIPC) promotes the prevention of Traumatic Brain Injury (TBI) through the provision of funding and technical assistance to states in order to strengthen state capacity around effective strategies. Additionally, NCIPC focuses on improving the recognition of and response to TBI through educational initiatives. NCIPC is devoted to preventing these injuries and mitigating the negative consequences once these injuries occur. Currently, NCIPC addresses TBI through research and programmatic activities that focus on various mechanisms of injury including motor vehicle crashes, falls, and violence. The purpose of this project is to conduct 60-minute small group discussions with state TBI prevention workers to gather feedback related to current CDC-supported TBI prevention efforts and how CDC can better support these efforts in the future. The information collected will be used to refine NCIPC’s strategy planning and help identify ways in which the agency can effectively improve, expand, and/or streamline the services provided to state health departments and other stakeholders.

DESCRIPTION OF RESPONDENTS:

State prevention workers (mostly from state health departments) who have an interest/involvement in TBI prevention

TYPE OF COLLECTION: (Check one)

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

[ ] Usability Testing (e.g., Website or Software [X] 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:______________ Karen Angel MS, MPH ______________________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [X] Yes [ ] No

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

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ X] 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
State governments	35	1 hour	35 hours
Totals	35		35 hours

FEDERAL COST: $102, 848

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 include:

• Members of Safe States Alliance’s State Designated Representative Special Interest Group, which includes directors of state injury and violence prevention programs

• Team leaders of the Children’s Safety Network’s Traumatic Brain Injury Communities of Practice (CoP)

Potential respondents will be invited to participate via email. Participation is completely voluntary. The goal is to recruit 30 states; however recruitment will not exceed 35 states.

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

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

3