Fast Track Form_PYP TA Grantee Feedback Survey

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

TITLE OF INFORMATION COLLECTION: Feedback on the Provision of Technical Assistance for Personal Responsibility Education Innovative Strategies Program (PREIS) and Tribal PREP (TPREP) Grantees

PURPOSE: On behalf of the Family and Youth Services Bureau (FYSB), the Office of Planning, Research, and Evaluation (OPRE) at the U.S. Department of Health and Human Services (HHS) oversees evaluation technical assistance to grantees funded under the Personal Responsibility Education Program (PREP) as part of the 2010 Affordable Care Act. OPRE requests permission for the technical assistance contractor, Mathematica, to contact Personal Responsibility Education Innovative Strategies Program (PREIS) and Tribal PREP (TPREP) grantee organizations for the purpose of gathering feedback on the provision of evaluation technical assistance. The contractor will collect information from grantee program and evaluation leads to assess the quality of the content and delivery of technical assistance and suggestions for future technical assistance.

DESCRIPTION OF RESPONDENTS: The contractor will contact all current PREIS and Tribal PREP grantee program directors and evaluation leads.

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: ____Selma Caal, Ph. D., Social Science Research Analyst____________

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	Participation Time	Burden
Private Sector (Anonymous web survey)	40	15 minutes	10 hours
Totals	40		10 hours

FEDERAL COST: The estimated annual cost to the Federal government is $1,448.

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?

All 12 PREIS and 8 Tribal PREP grantees will receive surveys. Two individuals, the project director and lead evaluator, for each grantee would receive each survey referenced below. The survey would be sent to grantees one time. Therefore, we expect to have 40 responses (20 grantees, 2 respondents per grantee).

Administration of the Instrument

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

[ X ] Web-based or other forms of Social Media – web-based survey

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

3