Request for Approval

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-1050)

Instruction: This form should be completed by the primary contact person from the Program sponsoring the collection.

DETERMINE IF YOUR COLLECTION IS APPROPRIATE FOR THIS GENERIC CLEARANCE MECHANISM:

Instruction: Before completing and submitting this form, determine first if the proposed collection is consistent with the scope of the Collection of Routine Customer Feedback generic clearance mechanism. To determine the appropriateness of using the Collection of Routine Customer Feedback generic clearance mechanism, complete the checklist below.

If you select “yes” to all criteria in Column A, the Collection of Routine Customer Feedback generic clearance mechanism can be used. If you select “yes” to any criterion in Column B, the Collection of Routine Customer Feedback generic clearance mechanism cannot be used.

Column A	Column B
The information gathered will only be used internally to CDC. [ X ] Yes [ ] No	Information gathered will be publicly released or published. [ ] Yes [ X] No
Data is qualitative in nature and not generalizable to people from whom data was not collected. [ X] Yes [ ] No	Employs quantitative study design (e.g. those that rely on probability design or experimental methods) [ ] Yes [ X ] No
There are no sensitive questions within this collection (e.g. sexual orientation, gender identity). [ X] Yes [ ] No	Sensitive questions will be asked (e.g. sexual orientation, gender identity). [ ] Yes [ X] No
Collection does not raise issues of concern to any other Federal agencies. [ X] Yes [ ] No	Other Federal agencies may have equities or concerns regarding this collection. [ ] Yes [X ] No
Data collection is focused on determining ways to improve delivery of services to customers of a current CDC program. [X ] Yes [ ] No	Data will be used to inform programmatic or budgetary decisions, for the purpose of program evaluation, for surveillance, for program needs assessment, or for research. [ ] Yes [ X ] No
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. [ X ] Yes [ ] No

Did you select “Yes” to all criteria in Column A?

If yes, the Collection of Routine Customer Feedback generic clearance mechanism may be appropriate for your investigation. You may proceed with this form.

Did you select “Yes” to any criterion in Column B?

If yes, the Collection of Routine Customer Feedback generic clearance mechanism is NOT appropriate for your investigation. Stop completing this form now.

Note: Use OMB format when asking race/ethnicity as well as gender questions.

TITLE OF INFORMATION COLLECTION: Violence Prevention Technical Assistance Center: Needs Assessment and Feedback

PURPOSE:

The Centers for Disease Control and Prevention’s (CDC’s) release of Preventing Multiple Forms of Violence: A Strategic Vision for Connecting the Dots (CDC, 2016) outlined a comprehensive approach to violence prevention that integrates risk and protective factors as well as prevention strategies for multiple forms of violence. The Violence Prevention Technical Assistance Center (VPTAC) brings into practice Connecting the Dots for CDC’s violence prevention programs. VPTAC assists the CDC’s Division of Violence Prevention and its Prevention Practice and Translation Branch (PPTB) by supporting violence prevention program recipients in successfully achieving program-specific objectives related to implementation, evaluation, and translation of approaches and strategies based on the best available evidence.

To achieve its objectives, VPTAC must assess program recipients’ training and technical assistance needs. A needs assessment serves as a critical step in ensuring that training and technical assistance provided will be relevant and directed toward building the right capacities to accomplish program-specific requirements. The purpose of the needs assessment survey is to understand the type and intensity of assistance PPTB-funded recipients need to accomplish the requirements outlined in their Notice of Funding Opportunities (NOFOs), as well as training and technical assistance needs related to implementing cross-cutting approaches to prevent multiple forms of violence. Needs Assessment Survey data will be used to inform a comprehensive training and technical assistance plan for VPTAC’s services and products.

VPTAC will also collect information regarding the quality, satisfaction, and perceived usefulness of training and technical assistance. The purpose of this data collection is to understand recipients’ satisfaction with training and technical assistance, including their perceptions of the quality and usefulness of the training and technical assistance. These data will be collected from attendees after training and technical assistance. Participant Feedback Form data will be used to understand recipients’ perceptions about what is working well and to guide VPTAC in continuously improving future training and technical assistance.

Data collection is focused on determining ways to improve delivery of services to customers of a current CDC program. Information gathered via will be used only internally for general service improvement and is not intended for release outside of the agency. Information gathered will not be used for the purpose of substantially informing influential policy decisions. Without the information collected through the needs assessment, PPTB will lack timely information to adjust its services to meet customer needs.

DESCRIPTION OF RESPONDENTS:

These data will be collected from representatives of 75 PPTB-funded recipients across four programs that are addressing different forms of violence. Due to the limited number of maximum respondents, all 75 grant recipients will be invited to participate in this assessment. No sampling will be conducted.

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 [X] Other: Needs Assessment for Training and Technical Assistance

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 who may have experience with the program in the future.

Name: Karen Angel

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

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 [X] No

3. If applicable, has a System or Records Notice been published? [ ] Yes [X] No

Privacy Act does not apply for this information collection request. (Att 1). All procedures have been developed, in accordance with federal, state and local guidelines, to ensure that the rights and privacy of respondents will be protected and maintained.

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	Form Name	Number of Respondents	Participation Time (Hours)	Burden (Hours)
PPTB-funded recipients	Needs Assessment Survey (Att 2 )	150	20/60	50
	Participant Feedback Survey (Att 3)	374	10/60	62
Totals				112

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

75 respondents are expected to respond to the Needs Assessment Survey. Each respondent will be a representative of one of 75 unique local, state, district, or territory health departments or coalitions that are participating in one of four PPTB -funded violence prevention programs (as detailed above). These respondents are the most knowledgeable about the information being collected in this assessment. Anyone who participates in VPTAC’s training and technical assistance will be invited to complete the Participant Feedback Form.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[] Web-based or other forms of social media

[ ] Telephone

[ ] In-person

[ ] Mail

[ X ] Other; explain – Surveys email

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

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