FastTrack GenIC Submission Form - MIECHV TA Survey and Immediate Feedback Tool

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

TITLE OF INFORMATION COLLECTION: Tribal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Technical Assistance Evaluation (TA) Survey and Immediate Feedback Tool

PURPOSE: The Administration for Children and Families (ACF), U.S. Department of Health and Human Services (HHS), proposes to collect feedback on the quality of TMIECHV TA provided by the TA provider Programmatic Assistance for Tribal Home Visiting (PATH).

The goals are to obtain information about grantee satisfaction with PATH TA, assess opportunities for improvement, identify gaps in services, and inform ACF decision-making around program support for the future planning and provision of program implementation support. These TA evaluation surveys were previously approved under OMB Control No.: 0970-0401 and have since been updated.

TMIECHV aims 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.

This generic clearance will allow ACF to receive feedback from TMIECHV grantees to assess the quality of training and TA and the grantee’s experience with TA. Feedback data will assist ACF with planning and improving the provision of annual TMIECHV TA.

The following surveys are included with this submission:

• Appendix A: PATH Technical Assistance Immediate Feedback Form

• Appendix B: PATH Technical Assistance Evaluation Feedback Form

DESCRIPTION OF RESPONDENTS:

Participants of PATH TA and this evaluation are current and future grantees who receive a TMIECHV grant from ACF to implement evidence-based home visiting services. This includes tribes, tribal organizations, and urban Indian organizations.

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 to substantially inform 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, HHS

To assist with the 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 and Instrument	No. of Respondents	No. of Responses per Respondent	Participation Time	Burden
Individual; Appendix A: Immediate Feedback Form	19	10	6 minutes	19
Individual; Appendix B: Evaluation Feedback Form	23	1	30 minutes	11.5
Totals	42			30.5

FEDERAL COST: The estimated annual cost to the Federal government is $10,281.89.

Type of Cost	Description of Services	Annual Cost
PATH Immediate and Evaluation Feedback Forms	Modifications, maintenance, data cleaning, and aggregation of the evaluation survey	$8,366.89
Government Program Analyst (25 hours annually)	Project management and oversight, and consultation.	$1,915
Total Estimated Annual Cost		$10,281.89

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?

We will not utilize a sampling plan. All potential respondents are current and future grantees who receive a TMIECHV grant from ACF to implement evidence-based home visiting services.

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

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