memo

OMB 0990-0379

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 0990-0379)
TITLE OF INFORMATION COLLECTION: Surveys to Inform Service Delivery
Improvement of Teen Intervene Curriculum with Mental Health Providers and Adolescent
Clients
PURPOSE:
The Lakes Health Center (DBA NorthLakes Community Clinic or NLCC) is piloting an adapted
Teen Intervene (TI) curriculum for use in a mental health setting as a primary and secondary
intervention strategy for at-risk adolescent girls (as defined by Adverse Childhood Experiences).
TI is an evidence based program that includes a low-cost SBIRT (Screening, Brief Intervention,
Referral to Treatment) and helps teens self-identify a substance use disorder, provides a brief
plan for intervention, and guides referral to treatment. The program includes two to three one-onone sessions (which may or may not include parents/families) and is a unique comprehensive
program created specifically to drive adolescent engagement and produce positive outcomes.
In a workshop setting, school-based and clinic-based mental health providers that work with
youth will be trained in TI and together with Alcohol and Other Drug Abuse (AODA)/recovery
professionals they will make necessary adjustments to the TI program for use as a primary
intervention strategy for use in a clinical setting. Those providers will then apply TI tools in
their mental health sessions with their at-risk adolescent girl clients.
We have developed pre and post workshop surveys for providers to determine effectiveness of
programming and to inform service delivery improvement. One of the desired outcomes of the
TI mental health provider workshop is to increase provider comfort levels, skills, knowledge and
awareness of substance use disorders, SU screening, primary and secondary prevention
strategies, and help them identify when to refer to recovery services. The mental health provider
survey (Attachment A) will be administered both pre and post workshop. It will use the Likertscale to collect qualitative data from all participating mental health providers (approximately 20).
Questions address confidence levels in utilizing screening tools, on determining whether or not
to use TI, providing TI in a manner that is trauma informed and culturally sensitive, and in
applying other elements of the TI curriculum.
The adapted TI curriculum is intended to impart skills that will help adolescent girls deal with
peer pressure, enhance decision making skills, reinforce social support systems and increase their
awareness of the pros and cons of opioid use (and other substances). The adolescent client
survey (Attachment B) will use a combination of Likert-scale and Yes/No responses to collect
qualitative data from participating adolescent girls (approximately 150) over 3 years.
Participation and survey completion will be voluntary.
DESCRIPTION OF RESPONDENTS:
Mental health provider survey (Attachment A) respondents will consist of mental health
providers in clinical practice that are providing mental health counseling services to adolescent
girls at Ashland Middle and High Schools and at NorthLakes Community Clinic Locations.
Mental health providers are a mix of NorthLakes, private practice, Ashland County, Bad River
Tribe Behavioral Health Clinic and Memorial Medical Center providers. Teen Survey
(Attachment B) respondents will consist of adolescent girls with ACEs receiving mental health
counseling services in Ashland Middle and High Schools and at NorthLakes Community Clinic

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OMB 0990-0379

locations, who will be receiving Teen Intervene curriculum from mental health providers during
their counseling sessions.
TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[] Focus Group

[X ] Customer Satisfaction Survey
[ ] Small Discussion 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:__Michelle Hoersch____________________________
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 [ X ] 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
7
50
57

Private Sector Survey A
Private Sector Survey B
Totals

Participation
Time
5 min
5 min
5 min

Burden
0.58
4.17
4.75

FEDERAL COST: 0
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
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OMB 0990-0379

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?
For Survey 1 (Attachment A) we will recruit participants from all providers that attend the Teen
Intervene workshop attempting to achieve 100% participation. For Survey 2 (Attachment B) we
will recruit participants from all adolescent girls that participate in Teen Intervene curriculum
with their mental health counselors.
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 , pen and paper
[ ] 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.

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OMB 0990-0379

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.

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

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