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: Midpoint Program Satisfaction Survey for Teen Leaders

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. As part of the program, Teen Leaders recruit youth participants, teach the 10 lessons, and lead the final project. The Media-Smart Youth program provides teens with leadership experience, community service hours, and recognition from the NICHD. To help them 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.

We are proposing to administer two customer satisfaction surveys with the Teen Leaders of the program—a midpoint survey and a final survey. The midpoint survey will be administered when sites have completed half of the program curriculum (through Lesson 5). The purpose of the midpoint survey is to assess Teen Leader satisfaction midway through the program and to identify areas for midcourse corrections to make improvements.

DESCRIPTION OF RESPONDENTS:

The respondents for the survey will be Teen Leaders in the Media-Smart Youth Teen Leaders Program. Each participating site may have one or more Teen Leader; however, one Teen Leader from each site will be asked to respond to the survey, for a total of 59 respondents. Teen Leaders vary in age from 15 to 20 years old. They have familiarity with the Media-Smart Youth program and a demonstrated interest in public health outreach efforts.

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	59	20/60	20
Totals	59		20

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 Teen Leaders from each site participating in the Media-Smart Youth Teen Leader program. Respondents will be identified through program applications obtained from the sites. There are a total of 59 sites, and one Teen Leader from each site will respond to the survey.

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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