Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0970-0401)
TITLE OF INFORMATION COLLECTION: Tribal Home Visiting Technical Assistance Evaluation Feedback and Immediate Feedback Forms

PURPOSE: 
The Administration for Children and Families (ACF), U.S. Department of Health and Human Services (HHS), requests approval to collect feedback about the quality of Tribal Maternal, Infant, and Early Childhood Home Visiting (TMIECHV) Technical Assistance (TA). 

The TMIECHV Program is designed to develop and strengthen tribal capacity to support and promote the health and well-being of American Indian and Alaska Native (AIAN) families; expand the evidence-base around home visiting in tribal communities; and support and strengthen cooperation and linkages between programs that service AIAN children and their families.

The goal of the information collections under this approval is to obtain information about grantee satisfaction with Programmatic Assistance for Tribal Home Visiting (PATH)  TA, assess and target opportunities for improvement, identify where there are gaps in services and to inform ACF decision-making around program support for future planning and provision of program implementation support. 

These information collections are not highly systematic or intended to be statistically representative or otherwise generalizable. ACF proposes using two surveys to reach this goal. 

Data collection will be conducted through a contract with the TA provider PATH funded by ACF, and overseen by the Office of Child Care, Tribal MIECHV program. 

DESCRIPTION OF RESPONDENTS: 

The TMIECHV program created in 2010, as part of the MIECHV program, includes a 3% set-aside for grants to tribes, tribal organizations, and urban Indian organizations to address concerns that existing home visiting approaches may not adequately meet the particular needs and circumstances of AIAN communities. 

Participants of PATH TA and this evaluation are current and future grantees who received a TMIECHV grant from ACF to implement evidence-based home visiting services. Grants are generally awarded for five years. Thus, grantees are at various stages of implementation (just starting or implementing for several years). 

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: Anne Bergan, Senior Policy Analyst, Office of Child Care, Administration for Children and Families 

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?  [  ] Yes [X] No  

BURDEN HOURS 

Category of Respondent 	No. of Respondents	No. of Responses	Participation Time	Burden (hours)	
Individual: Immediate Feedback Poll	23	4	.1 (6 minutes)	9.2	
Individual: Evaluation Survey	23	1	.33 (19.8 minutes)	7.59	
				16.79	
FEDERAL COST:  The estimated annual cost to the Federal government is $4,000 in contract support to collect, analyze and report findings to ACF.

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?

While we do know the universe of potential respondents, PATH will not utilize a sampling plan. All current and future grantees who received a TMIECHV grant from ACF to implement evidence-based home visiting services are potential respondents for completing the evaluation survey.

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.  Note:  Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

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 per row. 
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.

Submit all instruments, instructions, and scripts are submitted with the request.