DOCUMENTATION FOR THE GENERIC CLEARANCE

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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: XXXX-YYYY)
TITLE OF INFORMATION COLLECTION: 
 
CROSS-SITE EVALUATION OF THE OFFICE ON WOMEN’S HEALTH 
PREVENTION OF OPIOID MISUSE IN WOMEN: OFFICE ON WOMEN’S HEALTH PREVENTION AWARDS (OWPHA)

PURPOSE:  


The Office on Women’s Health Prevention Awards Project (OWPHA) provides funding to 20 organizations undertaking primary and/or secondary opioid misuse prevention efforts, and includes partnership and collaboration components. The funded organizations work to achieve this goal through: (1) program development and implementation; (2) health education targeting professionals and/or women directly, and (3) policy effort to support primary and/or secondary prevention.

Each quarter, OWH has collected qualitative and quantitative data in the form of grantee progress reports to assess grantees’ program partnerships, outcomes, and activities, including media campaigns; presentations, publications, and products; sustainability; federal resources; educational trainings; and technical assistance.

The purpose of this generic collection is to gather customer feedback to enhance existing evaluation efforts by obtaining qualitative data across the 20 grantee organizations from 1 respondent per organization on issues that support best practices in community-level project implementation.  It will also assess strategies used to overcome any challenges and overall lessons learned.


DESCRIPTION OF RESPONDENTS: 
The respondents will include one respondent from each of the 20 OWHPA grantee organizations in addition to one partner of each grantee organization. There will be a total of 40 participants in the interviews. 


TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form 	[ ] Customer Satisfaction Survey    
[ ] Usability Testing (e.g., Website or Software	[ ] Small Discussion Group
[X]  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:__Candace Marshall __________________________________

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
Participation Time
Burden
OWHPA grantees
20
1 hour
20 hrs
Partners of OWHPA grantees
20
1 hour
20 hrs
Totals


40 hrs


FEDERAL COST:  The estimated annual cost to the Federal government is  __$1,968.40_
Type of Respondent

Total Burden Hours
Hourly Wage
Rate
Total
Respondent Costs
Grantee Project Directors/ Points of Contact1
20
$50.47
$1,0009.40
Organizational Partner Points of Contact2
20
$47.95
$959.00
Total


$1,968.40


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?

The respondents will be represent the OWHPA grantee organizations in addition to one partner of each grantee organization. There are 20 grantees so the total number 

Administration of the Instrument
    1. How will you collect the information? (Check all that apply)
[  ] Web-based or other forms of Social Media 
[  X] Telephone	
[  ] In-person	
[  ] Mail 
[  ] Other, Explain

    2. Will interviewers or facilitators be used?  [X  ] Yes [  ] 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.