| Respondent Type |
Respondent Description |
Type of Survey Instrument |
Appendix |
Sample size |
Number of Respondents |
Frequency of Response (annual) |
Total Annual Responses |
Average Hours per Response |
Sub-Total Annual Burden |
Number of non -respondents |
Frequency of Response (annual) |
Total Annual Responses |
Average Hours per response |
Sub-Total Annual Burden |
Total Burden Hours |
Hourly Rate |
Total Annualized Cost |
| State/Local Government |
|
Telephone call to recruit Sponsors for instrument testing (a) (5 min) |
A.1 |
4 |
3 |
1 |
3 |
0.0835 |
0.2505 |
1 |
1 |
1 |
0.0167 |
0.02 |
0.2672 |
53.15 |
14.20 |
| Email data collection instruments and discussion time to Sponsors (b) (1 min) |
A.2 |
3 |
3 |
1 |
3 |
0.0167 |
0.0501 |
0 |
1 |
0 |
0.0167 |
0 |
0.0501 |
53.15 |
2.66 |
| Conduct cognitive testing and schedule QI interview time (b) (1 hour) |
A.3, A.4, A.5, A.6, D.1 |
2 |
2 |
1 |
2 |
1.0000 |
2.0000 |
0 |
1 |
0 |
0.0167 |
0 |
2.0000 |
53.15 |
106.30 |
| Email with QI appointment time (b) (1 min) |
A.7 |
2 |
2 |
1 |
2 |
0.0167 |
0.0334 |
0 |
1 |
0 |
0.0167 |
0 |
0.0334 |
53.15 |
1.78 |
| Cognitive testing of QI with Sponsors (b) (1 hour) |
A.8, D.1 |
2 |
2 |
1 |
2 |
1.0000 |
2.0000 |
0 |
1 |
0 |
0.0167 |
0 |
2.0000 |
53.15 |
106.30 |
| Telephone call to recruit Former Sponsors for instrument testing (a) (5 min) |
A.1 |
4 |
3 |
1 |
3 |
0.0835 |
0.2505 |
1 |
1 |
1 |
0.0167 |
0.02 |
0.2672 |
53.15 |
14.20 |
| Email Former Sponsors: schedule for instrument testing (b) (1 min) |
A.7 |
3 |
3 |
1 |
3 |
0.0167 |
0.0501 |
0 |
1 |
0 |
0.0167 |
0 |
0.0501 |
53.15 |
2.66 |
| Cognitive testing of QI with Former Sponsors (b) (30 minutes) |
B.1, D.1 |
2 |
2 |
1 |
2 |
0.5000 |
1.1250 |
0 |
1 |
0 |
0.0167 |
0 |
1.1250 |
53.15 |
59.79 |
| SUBTOTAL OF CN SFSP and SSO SPONSORS |
8 |
6 |
3 |
20 |
0.2844 |
5.76 |
2 |
1 |
2 |
0.0167 |
0.03 |
5.79 |
53.15 |
307.90 |
| CN SSO and SFSP Site Supervisors |
Telephone call to recruit Site supervisors for instrument testing (b) (5 min) |
A.1 |
4 |
4 |
1 |
4 |
0.0835 |
0.3340 |
0 |
1 |
0 |
0.0167 |
0 |
0.3340 |
53.15 |
17.75 |
| Email data collection instruments and discussion time to Site supervisors (b) (1 min) |
A.2 |
3 |
3 |
1 |
3 |
0.0167 |
0.0501 |
0 |
1 |
0 |
0.0167 |
0 |
0.0501 |
53.15 |
2.66 |
| Conduct cognitive testing and schedule QI interview time (b) (1 hour) |
C.1, A.4, A.5, A.6, D.1 |
2 |
2 |
1 |
2 |
1.0000 |
2.0000 |
0 |
1 |
0 |
0.0167 |
0 |
2.0042 |
53.15 |
106.52 |
| Email thank you letter and QI scheduled time to Site supervisors (b) (1 min) |
A.7 |
2 |
2 |
1 |
2 |
0.0167 |
0.0334 |
0 |
1 |
0 |
0.0167 |
0 |
0.0334 |
53.15 |
1.78 |
| Cognitive testing of QI with Site supervisors (b) (1 hour) |
C.2, D.1 |
2 |
2 |
1 |
2 |
1.0000 |
2.0000 |
0 |
1 |
0 |
0.0167 |
0 |
2.0000 |
53.15 |
106.30 |
|
SUBTOTAL OF CN SFSP AND SITE SUPERVISORS |
4 |
4 |
3 |
13 |
0.3398 |
4.42 |
0 |
0 |
0 |
0.0000 |
0 |
4.42 |
53.15 |
235.01 |
| GRAND TOTAL OF STATE/LOCAL GOVERNMENT |
|
12 |
10 |
3 |
33 |
0.3061 |
10 |
2 |
1 |
2 |
0.0188 |
0 |
10 |
|
542.91 |
| Nonprofit Organizations |
|
Telephone call to recruit Sponsors for instrument testing (a) (5 min) |
A.1 |
4 |
3 |
1 |
3 |
0.0835 |
0.2505 |
1 |
1 |
1 |
0.0167 |
0.02 |
0.2672 |
53.15 |
14.20 |
| Email data collection instruments and discssuion time to Sponsors (b) (1 min) |
A.2 |
3 |
3 |
1 |
3 |
0.0167 |
0.0501 |
0 |
1 |
0 |
0.0167 |
0 |
0.0501 |
53.15 |
2.66 |
| Conduct cognitive testing and schedule QI interview time (b) (1 hour) |
A.3, A.4, A.5, A.6, D.1 |
2 |
2 |
1 |
2 |
1.0000 |
2.0000 |
0 |
1 |
0 |
0.0167 |
0 |
2.0000 |
53.15 |
106.30 |
| Email with QI appointment time (b) (1 min) |
A.7 |
2 |
2 |
1 |
2 |
0.0167 |
0.0334 |
0 |
1 |
0 |
0.0167 |
0 |
0.0334 |
53.15 |
1.78 |
| Cognitive testing of QI with Sponsors (b) (1 hour) |
A.8, D.1 |
2 |
2 |
1 |
2 |
1.0000 |
2.0000 |
0 |
1 |
0 |
0.0167 |
0 |
2.0000 |
53.15 |
106.30 |
| Telephone call to recruit Former Sponsors for instrument testing (a) (5 min) |
A.1 |
4 |
3 |
1 |
3 |
0.0835 |
0.2505 |
1 |
1 |
1 |
0.0167 |
0.02 |
0.2672 |
53.15 |
14.20 |
| Email Former Sponsors: schedule for instrument testing (b) (1 min) |
A.7 |
3 |
3 |
1 |
3 |
0.0167 |
0.0501 |
0 |
1 |
0 |
0.0167 |
0 |
0.0501 |
53.15 |
2.66 |
| Cognitive testing of QI with Former Sponsors (b) (30 minutes) |
B.1, D.1 |
3 |
3 |
1 |
3 |
0.5000 |
1.5000 |
0 |
1 |
0 |
0.0167 |
0 |
1.5000 |
53.15 |
79.73 |
| SUBTOTAL OF CN SFSP AND SSO SPONSORS |
8 |
6 |
4 |
21 |
0.2921 |
6.13 |
2 |
1 |
2 |
0.02 |
0.03 |
6.17 |
53.15 |
327.83 |
| CN SFSP and SSO Site Supervisors |
Telephone call to recruit Site supervisors for instrument testing (b) (5 min) |
A.1 |
4 |
4 |
1 |
4 |
0.0835 |
0.3340 |
0 |
1 |
0 |
0.0167 |
0 |
0.3340 |
53.15 |
17.75 |
| Email data collection instruments and discussion time to Site supervisors (b) (1 min) |
A.2 |
3 |
3 |
1 |
3 |
0.0167 |
0.0501 |
0 |
1 |
0 |
0.0167 |
0 |
0.0501 |
53.15 |
2.66 |
| Cognitive testing and schedule QI (b) (1 hour) |
C.1, A.4, A.5, A.6, D.1 |
2 |
2 |
1 |
2 |
1.0000 |
2.0000 |
0 |
1 |
0 |
0.0167 |
0 |
2.0000 |
53.15 |
106.30 |
| Email with QI appointment time (b) (1 min) |
A.7 |
2 |
2 |
1 |
2 |
0.0167 |
0.0334 |
0 |
1 |
0 |
0.0167 |
0 |
0.0334 |
53.15 |
1.78 |
| Cognitive testing of QI with Site supervisors (b) (1 hour) |
C.2, D.1 |
2 |
2 |
1 |
2 |
1.0000 |
2.0000 |
0 |
1 |
0 |
0.0167 |
0 |
2.0000 |
53.15 |
106.30 |
|
SUBTOTAL OF CN SFSP AND SSO SITE SUPERVISORS |
4 |
4 |
3 |
13 |
0.3398 |
4.42 |
0 |
0 |
0 |
0 |
0 |
4.42 |
53.15 |
234.79 |
| GRAND TOTAL OF BUSINESS NONPROFIT ORGANIZATIONS |
|
12 |
10 |
3 |
34 |
0.3104 |
10.55 |
2 |
1 |
2 |
0.0167 |
0.03 |
10.59 |
|
562.62 |
| Individuals and households |
Parents/Caregivers of SFSP/SSO Participants and nonparticipants |
Study voicemail message for inbound calls from interested caregivers (1 min) |
E.1 |
40 |
40 |
1 |
1 |
0.0167 |
0.0167 |
0 |
1 |
0 |
0.0000 |
0 |
0.0167 |
7.25 |
0.12 |
| Outbound telphone calls to schedule cognitive testing interviews (c) (d) (10 min) |
E.2 |
32 |
26 |
1 |
26 |
0.1670 |
4.2752 |
6 |
1 |
6 |
0.0167 |
0 |
4.3821 |
7.25 |
31.77 |
| Confirmation email for cognitive testing (b) (2 minutes) |
E.3 |
23 |
23 |
1 |
23 |
0.0334 |
0.7695 |
0 |
1 |
0 |
0.0167 |
0 |
0.7695 |
7.25 |
5.58 |
| Cognitive testing of eligibility screener (c)(e) (10 min) |
E.4 |
18 |
18 |
1 |
18 |
0.1670 |
3.0781 |
0 |
1 |
0 |
0.0167 |
0 |
3.0781 |
7.25 |
22.32 |
| Caregiver consent (i) (5 min) |
E.5 |
18 |
18 |
1 |
18 |
0.0835 |
1.5030 |
0 |
1 |
0 |
0.0167 |
0 |
1.5030 |
7.25 |
10.90 |
| Cognitive testing of Caregiver surveys (e) (40 min) |
E.6, E.7 |
18 |
18 |
1 |
18 |
0.6680 |
12.0240 |
0 |
1 |
0 |
0.0167 |
0 |
12.0240 |
7.25 |
87.17 |
| Cognitive testing of caregiver QIs (e) (30 min) |
E.8, E.9 |
18 |
18 |
1 |
18 |
0.5000 |
9.0000 |
0 |
1 |
0 |
0.0167 |
0 |
9.0000 |
7.25 |
65.25 |
| Caregiver consent to interview child/teen (e) (5 min) |
E.10 |
18 |
18 |
1 |
18 |
0.0835 |
1.5030 |
0 |
1 |
0 |
0.0167 |
0 |
1.5030 |
7.25 |
10.90 |
| SUBTOTAL OF PARENTS/CAREGIVERS OF SFSP/SSO PARTICIPANTS AND NONPARTICIPANTS |
40 |
40 |
4 |
140 |
0.2297 |
32.17 |
6 |
1 |
6 |
0.02 |
0 |
32.28 |
7.25 |
234.00 |
| Child and Teen SFSP and SSO participants and nonparticipants |
Child assent (e) (5 min) |
E.11 |
9 |
9 |
1 |
9 |
0.0835 |
0.7515 |
0 |
1 |
0 |
0.0167 |
0 |
0.7515 |
7.25 |
5.45 |
| Teen assent (e) (5 min) |
E.12 |
14 |
14 |
1 |
14 |
0.0835 |
1.1690 |
0 |
1 |
0 |
0.0167 |
0 |
1.1690 |
7.25 |
8.48 |
| Cognitive testing of child survey (with parent) (e) (20 min) |
E.13 |
4 |
4 |
1 |
4 |
0.5000 |
2.0000 |
0 |
1 |
0 |
0.0167 |
0 |
2.0000 |
7.25 |
14.50 |
| Cognitive testing of teen surveys (20 min) |
E.14, E.15 |
14 |
14 |
1 |
14 |
0.5000 |
7.0000 |
0 |
1 |
0 |
0.0167 |
0 |
7.0000 |
7.25 |
50.75 |
|
SUBTOTAL OF CHILD AND TEEN SFSP/SSO PARTICIPANTS AND NONPARTICIPANTS |
23 |
23 |
2 |
41 |
0.2664 |
10.92 |
0 |
0 |
0 |
0 |
0 |
10.92 |
7.25 |
79.17 |
| GRAND TOTAL OF INDIVIDUALS AND HOUSEHOLDS |
|
63 |
63 |
3 |
181 |
0.2380 |
43.09 |
6 |
1 |
6 |
0.02 |
0.11 |
43.20 |
|
313.18 |
| OVERALL GRAND TOTAL FOR THE BURDEN REQUEST |
|
87 |
83 |
3 |
248 |
0.2570 |
63.82 |
10 |
1 |
10 |
0.02 |
0.18 |
64 |
|
1,418.71 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| (a) 75% of sampled respondents will respond to this data collection activity |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| (b) 100% of sampled participants will respond to this data collection activity |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| (c) 80% of respondents who agree will participate in this data collection activity |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| (d) 80% of respondents who leave a voicemail message on study toll free number will be reached |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| (e) 100% of respondents who arrive for cognitive testing will participate in this data collection activity |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|