Generic Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 1880-0542)

TITLE OF INFORMATION COLLECTION:

Regional Educational Laboratories (REL) Program Stakeholder Feedback Survey - Parents

PURPOSE:

The REL Stakeholder Feedback Survey is intended to capture timely feedback on products, activities and events developed by the ten Regional Educational Laboratories. This specific Stakeholder Feedback Survey has been adapted to collect feedback from parents/caregivers. The attached survey asks respondents about their satisfaction with REL webinars geared towards parents/caregivers.

The survey as administered will include 7 items—4 close-ended items and 3 open-ended items

Data obtained from the REL Stakeholder Feedback Survey will be used for program improvement purposes. For example, the data will assist REL staff in understanding the utility of activities, identifying areas of stakeholder need or concern, and identifying future research and technical assistance/support activities. In addition, these data will assist RELs in determining the extent to which they are meeting the expected outcomes of the REL program (as outlined in the 2017-2022 REL Performance Work Statement).

DESCRIPTION OF RESPONDENTS:

The category of respondents for this survey is: (1) Individuals or Households. The REL Stakeholder Feedback Survey will be administered to participants of REL dissemination events. This survey is specifically for parents/caregivers. All other REL activities will use the current Stakeholder Feedback Survey.

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: Janelle Sands _______________________________________________

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 [ ] 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

The estimated burden hours is 250 hours per year for recording keeping purposes only.

Category of Respondent	No. of Respondents	Participation Time	Burden
Parents/Caregivers	1000	15 minutes	250
Totals	1000	15 minutes	250

FEDERAL COST:

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

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? [ ] Yes [X ] 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 REL Stakeholder Feedback Survey will be administered to participants of REL events/activities (coaching/consultation meetings, workshops, trainings, technical support activities, webinars, etc.) and individuals who participate in REL research partnerships. REL staff will invite individuals to voluntarily complete the survey at the conclusion of an event/activity or during/after a regularly scheduled research partnership meeting. An optional follow-up survey may be administered approximately 3 months after an event/activity to individuals who receive ongoing partnership or training/coaching support.

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

[X] 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.

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.

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