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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:

Adolescent SBIRT (A-SBIRT) In-Person Training Feedback Surveys:

1. Satisfaction and Retrospective Knowledge and Awareness Survey

2. A-SBIRT 3 month/6 month Usage Feedback Survey(s)

PURPOSE:

The Connecticut Opioid Misuse Prevention (COMP) Initiative will provide Adolescent Screening Brief Intervention and Referral to Treatment (A-SBIRT) training for individuals throughout Connecticut who work with adolescent girls age 12-18. This new program run by Wheeler Clinic Inc. is funded through a prevention grant from the Office on Women’s Health (OWH), U.S. Department of Health and Human Services (HHS). The following Feedback surveys will be used.

a) Satisfaction and Retrospective Knowledge and Awareness Survey – the purpose of this survey is to assess the effectiveness of A-SBIRT Training. A-SBIRT trainees will complete the survey upon completion of the in-person training to assess satisfaction with the training and their perceived change in comfort utilizing different elements of A-SBIRT including assessment, brief intervention, and referral for substance use treatment for adolescent girls.

b) A-SBIRT 3 month/6 month Usage Feedback Survey(s) - the goal of CT Opioid Misuse Prevention (COMP) Initiative is to increase the use of A-SBIRT intervention among individuals who interact with adolescent girls age 12-18 in Connecticut. All trainees will be contacted at 3- and 6-months following A-SBIRT training to determine how frequently they have provided A-SBIRT services and how frequently they have referred an adolescent girl to treatment services. The A-SBIRT 3 month/6month Usage Feedback Survey(s) will be emailed to individuals via Survey Monkey.

DESCRIPTION OF RESPONDENTS:

Individuals throughout Connecticut who work with adolescent girls age 12-18 and who have completed A-SBIRT training under the auspices of the COMP program. These include prevention professionals, youth services workers, and school staff including school nurses and school-based health centers, pediatric primary care providers, community based professionals and community members.

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: a) Satisfaction and Retrospective Knowledge and Awareness Survey b) A-SBIRT 3 month/6 month Usage Feedback Survey(s)

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:__Laurie Robinson_____________________________________________

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

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	No. of Respondents	Participation Time	Burden
Individuals (first survey)	500	7/60	58.3
Individuals - 3 month follow up	500	7/60	58.3
Individuals – 6 month follow up	500	7/60	58.3
Totals	500	21/60	175

* Based on the surveys filled out by the testers.

FEDERAL COST: The estimated annual cost to the Federal government is _$1847.50_____

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? a) [ ] Yes [X] No

b) [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?

a) Wheeler’s Connecticut Clearinghouse has statewide reach with prevention professionals and the general public. The trainings will be marketed through the Connecticut Clearinghouse and Wheeler Facebook pages and the Connecticut Clearinghouse listserv that has 3,500 members.

b) We will have email addresses of all the individuals who complete the A-SBIRT training.

All the individuals who complete the A-SBIRT trainings under the auspices of the COMP program will receive the survey link via email.

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

[ X ] In-person

[ ] Mail

[ ]

2. Will interviewers or facilitators be used? [ ] Yes [ X ] No

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

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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