Request

OMB Control No: 0970-0401

Expiration date: 5/31/2018

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

TITLE OF INFORMATION COLLECTION:

AFI Grantee Workshop Evaluation Survey

PURPOSE:

The U.S. Department of Health and Human Services (HHS) Administration for Children and Families (ACF) Office of Community Services (OCS) administrates the Assets for Independence (AFI) demonstration program. OCS is holding a workshop for AFI grantees that want to attend on Sept. 27, 2016, the day before a large private conference that many grantees attend.

The purpose of the proposed meeting evaluation survey is to increase OCS’s understanding of the effectiveness of meetings of this type as well as to gain direct grantee input regarding topics and issues they would like to address in the future.

DESCRIPTION OF RESPONDENTS:

The respondents will be Assets for Independence grantees that have attended the workshop and who voluntarily complete the evaluation forms. All grantees were invited to attend the workshop.

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	75	.25 hour	18.75 hours
Totals	75	.25	18.75

FEDERAL COST: The estimated annual cost to the Federal government is $ 750.00

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?

An invitation to attend the workshop was issued to all current grantees of the AFI program. A portion of those that received the invitation have self-selected to attend the workshop. All grantees who attend the workshop will be asked to voluntarily complete the session evaluation. We expect between 60-75 workshop participants.

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? [ ] Yes [ X ] No

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

The survey will be passed out to workshop attendees, and the meeting facilitator will ask them to complete it and leave it in the room or provide it to a staff member.

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