Generic for Feedback Submission Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 3045-0137)

TITLE OF INFORMATION COLLECTION: Community Opinion Leaders Focus Group

PURPOSE:

Test to see how well our current brand is communicating to the public.

DESCRIPTION OF RESPONDENTS: Opinion leaders in St. Louis, MO

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: Haley Lamm

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? [X] Yes [ ] No $15.00

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Opinion Leaders in St. Louis, MO	25	2 hours	50
Totals	25	2 hours	50

FEDERAL COST: The estimated annual cost to the Federal government is $19,000 ($9,500 per focus group).

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?

Axis Research will work together with our facility partner in St. Louis, Missouri to recruit participants in a focus group to discuss the CNCS brand, its strengths, and its weaknesses. Participants will be recruited from a panel of area residents who have agreed to be focus group participants on important issues.

Participants will be called to make sure we recruit a mix of different backgrounds and confirm availability on the study date. A short screener will be utilized to ensure each participant is active in their community and engages on local issues. Participants will not be informed as to who sponsored the study, although the sponsor will be very apparent when the groups are concluded.

The same moderator will moderate both focus groups to eliminate any variation or bias between the groups. That moderator will also write a summary report to highlight the findings and comments from participants.

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 Screening call

[X] In-person Focus Group

[ ] 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

3