Form 1103-0117 Training Evaluation

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 1103-0117)

S UBCOMPONENT: DOJ/Community Relations Service

TITLE OF INFORMATION COLLECTION: Level 1 Evaluation of Programs sponsored by DOJ Community Relations Service (CRS)

PURPOSE:

The purpose of this collection is to gather feedback on services provided from the Civil Rights Division/Community Relations Service and programs from the US Attorney Office (USAO).

DESCRIPTION OF RESPONDENTS:

The respondents for the Community Relations Service surveys will be participants who attended workshops, community dialogues, and training. The participants can be faith-based leaders, law enforcement, facilitators, school administrators, students, community leaders, and representatives of advocacy organizations.

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: Program Participant Feedback Survey

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: Christopher Chalberg

Title: Program Manager

Office: DOJ-Community Relations Service

Desk Phone: 303.844.2975

Cell Phone: 303.301.5533

Email Address: [email protected]

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, 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? [ ] Yes [x] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Private Sector Participants in CRS training and facilitated dialogue programs	1000	1 minute	17
Totals	1000	1 minute	17 hours

Estimated Annual Reporting Burden
Type of Collection	No. of Respondents	Annual Frequency per Response	Hours per Response	Total Hours
CRS Training Programs	[1000]	[1]	[1 minute]	[17 hours]

FEDERAL COST: The estimated annual cost to the Federal government is $0.

These costs are comprised of:

[Provide an estimate of applicable costs: such as operational expenses (e.g., equipment, overhead, printing, postage and support staff), contractor payments and any other expense that is necessary to collect the information approved under this generic clearance.]

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

2. 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?

An evaluation is provided to each participant who attends any of the seven programs. Each participant has the opportunity to complete an evaluation by the end of the program or event.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[X] In-person

[ ] Mail

[ ] Other, Explain

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

The facilitator will collect the evaluations at the end of each program or event.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

The facilitator will review the evaluation form, including the instructions. The instructions are on the form and are stated as follows:

We greatly appreciate receiving your feedback, and we will use your responses to help improve the program.

Please rate how strongly you agree or disagree with each of the following statements by circling the

corresponding number.

For the following questions, please write your comments in print and as legibly as possible.

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