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: Nonprofit Partner 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 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. Each Teen Leader or group of Teen Leaders must enlist a nonprofit partner in their community to help transfer program funds. Many nonprofit partners will provide additional support in areas such as promotion, recruitment, and program implementation.

The purpose of this survey is to assess nonprofit partner satisfaction at the end of the Media-Smart Youth Teen Leaders Program to determine whether the NICHD needs to provide additional support to future nonprofit partners or make other improvements to the program.

DESCRIPTION OF RESPONDENTS:

The respondents for this survey will be nonprofit partners in the Media-Smart Youth Teen Leaders program. Each site has one nonprofit partner for a total of 59 survey respondents. Nonprofit partners have familiarity with the Media-Smart Youth program and a demonstrated interest in community outreach efforts. They represent a variety of different organizations, including schools, churches, 4-H clubs/cooperative extension programs, and other youth-serving community 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
Private Sector	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 nonprofit partners 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 nonprofit partner per site.

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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