Fast Track GenIC Request Zika Intercept Interview

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-1071)

TITLE OF INFORMATION COLLECTION: Formative Evaluation of Zika Prevention Kits for Pregnant Women in Puerto Rico

PURPOSE: The purpose of this request is to get feedback from pregnant women about the Zika Prevention Kit which is being proposed for distribution to all pregnant women in Puerto Rico as part of their response to the Zika virus.

DESCRIPTION OF RESPONDENTS: Up to 70 pregnant women who are participants of the Puerto Rico Women, Infants, and Children (WIC) program. We propose conducting brief intercept interviews with 8-10 pregnant women in one WIC clinic in each of Puerto Rico’s seven health districts.

TYPE OF COLLECTION: (Check one)

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

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [X ] Other: intercept interview___

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: Carmen Perez and Christine Prue

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ x ] Yes [ ] No Interviews will be recorded on a digital recording device so that interviewers don’t have to take notes. We are not asking participants for any identifying information (like their name) but their voice is unique and is being captured. As soon as the conversations are transcribed, the digital recordings will be destroyed. Transcripts will be used for analysis and will not contain any personally identifiable information.

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [x ] No

3. If Applicable, has a System or Records Notice 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	No. of Respondents	Participation Time	Burden
Individuals (Pregnant woman at WIC Clinics)	70	15 minutes	18 hours
Totals			18 hours

FEDERAL COST: The estimated annual cost to the Federal government is $17, 300.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

We do not plan to employ statistical methods for this project, though trained interviewers will conduct brief, in-person interviews of women at WIC clinics (“intercept interviews”)

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? [ ] Yes [X] 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?

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ x ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ x ] Yes [ ] No

Please make sure that all instruments, instructions, and scripts are submitted with the request.

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g., Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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