Fast Track Generic - Submission Template 2019 AGM Peer Sharing Session Survey_CLEAN

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

T ITLE OF INFORMATION COLLECTION: Maternal, Infant, and Early Childhood Home Visiting (MIECHV) AGM 2019 – Peer Sharing Feedback Survey

PURPOSE:

To collect feedback from grantees who plan to attend the 2019 Maternal, Infant, and Early Childhood Home Visiting (MIECHV) State, Territory, and Tribal All Grantee Meeting organized by the Administration for Children and Families and the Health Resources and Services Administration (HRSA). The meeting agenda includes a Peer Sharing Session. This brief survey will allow grantees to indicate their preferences for the topic and design of the Peer Sharing session (i.e., who do they want to connect with, what topics are most important to them, and what questions do they have of their peers around the topics they find most important). The survey responses will be used to design a session that is most responsive to grantee preferences.

DESCRIPTION OF RESPONDENTS:

The respondents are MIECHV State, Territory, and Tribal grantee team members who plan to attend the 2019 MIECHV AGM in February 2019. The respondents fill various roles on the grantee teams including program directors, program staff, and evaluators.

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: Nicole Denmark

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 (minutes)	Burden Hours
Grantee participants across various roles	350	5	29.2
Totals	350	5	29.2

FEDERAL COST: The estimated annual cost to the Federal government is $2000

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

The survey link will be sent by HRSA and ACF to those included on their grantee Listservs. The email will ask grantee leads to forward the links to those team members who plan on attending the 2019 MIECHV AGM. Approximately 350 grantee team members attended the past two AGMs. That source is used to estimate the number of respondents above.

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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