Generic Request Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-1009)

TITLE OF INFORMATION COLLECTION:

Recipient Meeting Participant’s Feedback - Division of Violence Prevention

PURPOSE:

The Division of Violence Prevention funds various state and local recipients to implement and evaluate violence prevention programs. As part of various cooperative agreements, CDC provides sponsored activities to support recipients with implementation and/or evaluation of their initiatives. The Prevention Practice & Translation Branch provides these sponsored activities in the form of technical assistance, training, resources, and supports to the funded awardees and practitioners in the field.

The purpose of this request is to gather timely feedback from individuals who attended the CE16-1605 Preventing Teen Dating and Youth Violence by Addressing Shared Risk and Protective Factors 2019 Recipient Meeting (August 6-8, 2019). The Recipient Meeting provided the local health department recipients and their partners with opportunities to receive technical assistance on the implementation, evaluation, and sustainability of comprehensive violence prevention strategies. Feedback gathered, including satisfaction with delivery and content, will help project officers and evaluation officers working with the recipients to better understand the capacity and supports needed by the recipients. The information collected will also provide a feedback mechanism to identify areas of improvement for future recipient meetings and technical assistance efforts and allow for ongoing communication and collaboration with funded recipients. Participant feedback is vital to ensure learning opportunities are beneficial for participants, and without such data collection this information would be unknown.

DESCRIPTION OF RESPONDENTS:

Potential respondents are individuals who attend the CE16-1605 Preventing Teen Dating and Youth Violence by Addressing Shared Risk and Protective Factors 2019 Recipient Meeting. Participants included local health department staff, public health practitioners, program staff, and researchers responsible for implementing and evaluating violence prevention programs and strategies.

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: Karen Angel

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 [X ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [X ] No

Privacy Act does not apply for this information collection request. (Att 3). Personal Private Information is not collected. All procedures have been developed, in accordance with federal, state and local guidelines, to ensure that the rights and privacy of respondents will be protected and maintained.

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [X ] No

BURDEN HOURS

The target respondents will all be participants at the 2019 Recipient Meeting. 42 individuals registered to attend the meeting. The web-based 2019 Recipient Meeting Feedback Survey (Attachment 1a&b) will be emailed (Attachment 2a) to participants upon OMB approval. The feedback form will open for three weeks, and a reminder (Attachment 2b) will be sent two days before the closing date. Participation in the data collection will be voluntary.

The 2019 Recipient Meeting Feedback Form consists of 5 parts and has 28 questions. Questions ask about the participants’ satisfaction with the meeting content and delivery; no personally identifiable information will be collected. Based on a pilot test with CDC fellows, the 2019 Recipient Meeting Form takes an average of nine minutes to complete. There will be no direct costs to the respondents other than their time to respond to the survey.

Category of Respondent	No. of Respondents	Form Name	Participation Time (Hours)	Burden (Hours)
Meeting Participants	42	Feedback Survey (Att.1a&b )	9/60	6 hrs
	42	Invitation Email (Att. 2a)	1/60	1 hr
	42	Reminder Email (Att. 2b)	1/60	1 hr
Total				8 hours

FEDERAL COST: The estimated annual cost to the Federal government is $965.40.

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?

The customer list will consist of the registration list for the recipient meeting. Individuals who registered for the recipient meeting represent recipients and partners.

No sampling will be conducted in order to gather feedback from any meeting participant who is willing to volunteer feedback.

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