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:

Assessing “Return to Learn” programs through an online survey

PURPOSE:

Return to Learn (RTL) programs assist school aged children who have experienced a concussion or other traumatic brain injury (TBI). They ensure adaptations are made to the student’s learning environment while the brain heals and symptoms resolve. These programs have emerged out of perceived need and are increasing in popularity, but few have been evaluated on program processes or the impact on students’ educational and health outcomes. CDC would like to obtain feedback from program administrators about their program improvement and assessment needs to inform future CDC service deliveries, products, and communication materials that can support RTL programs.

The purpose of this project is to identify RTL programs, assess their implementation and evaluation capacity, and identify needs for future services and products offered by CDC. The information collected will be used to determine what service delivery strategies are needed to augment program improvement and assessment products for RTL programs. The information will also be used to identify promising, scalable programs ready to be rigorously evaluated. This will ensure future evaluation resources are prioritized for those program(s) most likely to be effective and to yield productive findings.

DESCRIPTION OF RESPONDENTS:

Respondents are individuals who include key informants from state health departments, school districts, hospital systems, or concussion clinics who administer a school concussion RTL program or who are familiar with such programs being implemented at the state and local level.

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: on-line survey

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______________________________________

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, 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 (Hours)	Burden (Hours)
Individuals (program administrators/key informants)	50	30/60	25
Totals	50		25 hours

FEDERAL COST: $ 3525

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?

Customers are current and future administrators/key informants of RTL programs that may need assistance in planning and conducting program improvement and assessment activities.

We will identify a group of respondents by mass distributing an email announcement (Attachment A) through our regular communication channels. The distribution network will include TBI researchers, program grantees, and partner organizations.

The announcement will invite recipients to nominate their own RTL programs or other RTL programs with which they are familiar through a 30 minute online survey (Attachment B). Participation is completely 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

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