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

TITLE OF INFORMATION COLLECTION:

Promoting Older Women’s Engagement in Recovery (POWER) Seeking Safety Training Survey

PURPOSE:

This survey is part of the Promoting Older Women’s Engagement in Recovery (POWER) project being run by the Institute for Health and Recovery (IHR), located in Cambridge MA. POWER is funded through a prevention grant from the Office on Women’s Health. The project is focused on preventing opioid misuse and abuse in women ages 55 and up (55+), in the Massachusetts’ cities of Cambridge and Somerville. The project is designed to raise awareness of issues related to opioid misuse among women aged 55+ through public information, education, screening, and capacity building.

This survey will be distributed to staff of POWER’s partner organizations after they attend a training on using the evidence based intervention Seeking Safety presented by POWER trainers. Following the end of the training, trainers will distribute surveys to all participants. Participants are encouraged to complete the survey. They may write as many comments as they want, but they survey is designed to be time efficient.

The purpose of this survey is to measure project outcomes related to training staff at partner organizations on Seeking Safety. POWER seeks to train staff on using Seeking Safety with women 55+ as a means to intervene around risky substance use often connected with trauma. The survey asks about staffs’ increase of knowledge in several related areas and their self-reported ability to use new skills introduced in the training. We will use feedback gained from this survey to continue to improve future renditions of this training to make sure these outcomes are being met.

DESCRIPTION OF RESPONDENTS:

Respondents will consist of staff from multiple of POWER’s partner agencies. Our key contacts at each partner organization are internally selecting which of their departments and program staff would benefit most from these trainings. These trainings are being offered to staff as professional development at their various organizations. Generally the staff selected to participate in Seeking Safety trainings will be clinical therapeutic staff, such as social workers.

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: Post Seeking Safety Training Survey

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: Norma Finkelstein, Executive Director, Institute for Health and Recovery; Principle Investigator, POWER

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
Staff at Partner Agencies	10	4/60	40/60
Totals			40/60

*Burden hour estimate based on average time taken to complete survey by small sample group.

FEDERAL COST: The estimated annual cost to the Federal government is __$126_________

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?

As part of POWER, IHR is partnered with a number of organizations in the community who work directly with women ages 55+. IHR’S partner organizations are internally selecting the staff at their agencies that will be included in these trainings based on their job descriptions and departments. All staff that attends training on Seeking Safety as part of POWER will be provided this survey at the end of the training for evaluating the training.

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 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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