Fast-Track Template Submission Form

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0925-0643)

T ITLE OF INFORMATION COLLECTION:

Media-Smart Youth^® Teen Leaders Program: Advisor Satisfaction Survey

PURPOSE:

Media-Smart Youth: Eat, Think, and Be Active!^® is an interactive program designed to teach youth about how media can affect their health. Developed by the NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the program includes 10 lessons on media analysis, nutrition, and physical activity, plus a final capstone project.

The Media-Smart Youth^® Teen Leaders Program, newly launched in 2014, is designed for teens/young adults who are interested in bringing the Media-Smart Youth program to their community. In return for recruiting youth participants, teaching the 10 lessons, and leading the final project, Teen Leaders receive leadership experience, community service hours, and recognition from the NICHD. To help Teen Leaders succeed, the NICHD provides training, ongoing assistance, and $1,000 for program expenses.

The NICHD issued a call for applications for the Teen Leaders Program on September 15, 2014, and has since made 59 awards to sites across the country. Each Teen Leader or group of Teen Leaders must enlist a volunteer adult advisor in their community to help supervise the youth participants and oversee the program. The advisors’ activities may include providing help to develop program budgets, recruit participants, and facilitate lessons, among other activities.

The purpose of this survey is to assess the advisors’ satisfaction at the end of the Media-Smart Youth Teen Leaders Program to determine whether the NICHD needs to provide additional support to future Teen Leaders and advisors.

DESCRIPTION OF RESPONDENTS:

The respondents for this survey will be advisors in the Media-Smart Youth Teen Leaders Program. Each site has one advisor for a total of 59 survey respondents. Advisors vary in age from 21 years and up. They have familiarity with the Media-Smart Youth program and a demonstrated interest in public health outreach efforts. Some advisors are parents of Teen Leader awardees; others are teachers, school administrators, or staff of youth-serving organizations.

TYPE OF COLLECTION: (Check one)

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

[ ] Usability Testing (e.g., Website or Software [ ] 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: Katie Rush, Coordinator, Media-Smart Youth Program

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 [ ] No

3. If Applicable, has a System or Records Notice 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	Burden
Individuals or Households	13	30/60	7
Totals	13		7

FEDERAL COST: The estimated annual cost to the Federal government is $3,000.

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

The universe of potential respondents consists of advisors from each site participating in the Media-Smart Youth Teen Leaders program. Respondents will be identified through program applications obtained from the sites. There are a total of 59 sites with one advisor per site – at 46 sites, teachers, school administrators, or staff of youth-serving organizations serve as advisors, and at the remaining 13 sites parents or grandparents serve as advisors of the Teen Leaders.

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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