Justification

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”
(OMB Control Number 0970-0401)

TITLE OF INFORMATION COLLECTION:

AFI Capacity Building Visit Feedback Form

PURPOSE:

The U.S. Department of Health and Human Services (HHS) Administration for Children and Families (ACF) Office of Community Services (OCS) has contracted with the Corporation for Enterprise Development (CFED) to perform capacity building services for Assets for Independence (AFI) Program grantees. Through this contract, technical assistance providers from CFED conduct capacity building visits to grantees to help them set-up and implement their grants. The purpose of this survey is to collect feedback from grantees after each capacity building visit to learn from and improve the content of these visits.

DESCRIPTION OF RESPONDENTS:

The respondents will be Assets for Independence grantees that receive a capacity building visit from CFED, as approved by the AFI program manager. The AFI project coordinator at each site will be asked to complete this survey.

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:_ Gretchen Lehman______

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, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No [X ] Not applicable

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No [X] Not applicable

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	Estimated Number of Respondents	Estimated Participation Time	Estimated Burden
Individuals	100	.25 hours	25 hours
Local governments	0	0 hours	0 hours
Totals	100	.25	25

FEDERAL COST: The estimated annual cost to the Federal government is $605.40_

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?

CFED and the Assets for Independence Program have identified organizations that would benefit from capacity building visits, including new grantees. We will send the survey to them after they have received a capacity building visit. Anyone that receives an invitation may complete the survey; no sampling is involved.

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

Please submit all instruments, instructions, correspondences (emails, letters, etc.) to respondents, and scripts as separate documents along with this request document.

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