memo

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0990-0379)

TITLE OF INFORMATION COLLECTION: Senior Public Health Advisor

PURPOSE:

The OASH Insular Areas Improvement Initiative comprises two tasks which aim to: (1)

assess the root causes of challenges associated with the United States insular areas federal

resource management process and identify recommendations to address those challenges; (2) develop a healthcare service delivery planning tool for Freely Associated States (FAS) hospital and health leaders to assess hospital service needs and resources, identify resources required to meet those needs, and to help health leaders improve their systems of care. The purpose of the

small discussion groups is to help inform both tasks 1 and 2 of the initiative.

DESCRIPTION OF RESPONDENTS:

For task 1, we will conduct up to 16 small discussion groups consisting of HHS grant awardees in the insular areas. Up to 2 discussion groups will be held in each of the 8 insular areas, including Guam, Saipan (CNMI), Palau, Chuuk (Micronesia), Pohnpei (Micronesia), Pago Pago (American Samoa), Puerto Rico and the U.S. Virgin Islands. Each small discussion group will comprise up to 7 people.

For task 2, we will pilot test the planning tool though 3 small discussion groups – one group will be held at Palau, Chuuk, and Pohnpei. Each group will comprise up to 5 people.

TYPE OF COLLECTION: (Check one)

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

[ ] Usability Testing (e.g., Website or Software [X ] 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:__Subroto Banerji______________________________________________

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
Local and State Government-task 1	112	8	896
Local and State Government – task 2	15	3	45
Totals			941

FEDERAL COST: The estimated annual cost to the Federal government is _$161,129___________

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? [ ] 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?

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

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

3