Fast Track Submission Form - ANA Post Peer Panel Review Survey

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0970-0401)

TITLE OF INFORMATION COLLECTION: Administration for Native Americans (ANA) Post Peer Panel Review Survey

PURPOSE: The Administration for Native Americans (ANA) would like to learn more about participants’ experiences with ANA’s Peer Panel Review Process. Data collected from the proposed Communications Survey will be used to help ANA to plan future training and service improvements.

This is a request for approval by the Office of Management and Budget (OMB), under the Federal Paperwork Reduction Act of 1995, for a new data collection task to be added to the Administration for Children and Families’ already approved generic OMB clearance number 0970-0401.

DESCRIPTION OF RESPONDENTS: Survey respondents will tribal governments, Indian Tribes and tribal organizations, Alaska Native grantees, and non-profit Native American organizations.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [x] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] 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: Amy Zukowski, Director, Division of Program Evaluation and Planning, ACF Administration for Native Americans

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [x] Yes [ ] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [x] 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? [ ] Yes [X] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Private sector	100	10 minutes	17 hours
Totals			17 hours

FEDERAL COST: The estimated annual cost to the Federal government is approximately $500

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?

ANA is defining the universe of respondents as current ANA application peer panel reviewers. The survey will be sent out to these reviewers at the end of their review session.

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

[ ] 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.

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