RETA Fast Track Generic Submission Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0970-0401)

T ITLE OF INFORMATION COLLECTION: Rigorous Evaluation Technical Assistance (RETA) Feedback Form

PURPOSE: We request approval to collect customer service feedback on evaluation-focused technical assistance (called Rigorous Evaluation Technical Assistance, or “RETA”) delivered to grantees in two grant programs under the Personal Responsibility Education Program (PREP): the PREP Innovative Strategies (PREIS) program, and the Tribal PREP program. PREP is administered by the Administration for Children and Families (ACF).

As background, grantees in PREIS and Tribal PREP implement programs for youth that address both abstinence and contraception: grantee program staff carry out this programming. Grantees are also conducting evaluations (some impact in design, others descriptive in design) of the programming: these grantee-specific evaluations are called “local evaluations” in shorthand. Grantees hire independent evaluators to carry out evaluations: these evaluators are called “local evaluators” in shorthand. Grantee program staff and local evaluator staff receive evaluation-focused technical assistance (TA) services provided by Mathematica Policy Research, under contract to ACF. Customer service feedback will address this evaluation-focused TA.

DESCRIPTION OF RESPONDENTS:

Staff at each of the PREIS and Tribal grantees will be invited to respond, specifically:

• There are thirteen PREIS Grantees:

  • Up to three grantee program staff involved with implementing programming and coordinating with the local evaluator;

  • Up to three local evaluator staff.

• There are eight Tribal PREP Grantees:

  • Up to three grantee program staff involved with implementing programming and coordinating with the local evaluator;

  • Up to three local evaluator staff.

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:_Seth Chamberlain_______________________________________________

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

3. If Yes, has an up-to-date System of Records Notice (SORN) 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
Private sector (PREIS Grant – grantee program staff and local evaluator staff)	78	20 min	26 hours
Private sector (Tribal Grantees – grantee program staff and local evaluator staff)	48	20 min	16 hours
Totals	126	20 min average	42 hours

FEDERAL COST: The estimated annual cost to the Federal government is $1,373_______

For cost calculations, we estimate 10 hours of time for a GS-12, 10 hours for a GS-13, and 10 hours for a GS-14. These hours will be used by multiple ACF staff to create, distribute, collect, and review customer feedback.

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 [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?

We have lists of all grantees and local evaluators. Up to three staff from each grantee, and from each local evaluator, will be invited to respond to the customer service survey.

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

[X] Other, Explain: Word Template

2. Will interviewers or facilitators be used? [ ] Yes [X] 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. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

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 per row.

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.

Submit all instruments, instructions, and scripts are submitted with the request.

4