Fast Track GenIC Submission Form - State Repatriation Coordinator Feedback

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

TITLE OF INFORMATION COLLECTION: State Repatriation Coordinator Feedback

PURPOSE: The purpose of the State Repatriation Coordinator Feedback is to solicit input from state human services employees on topic areas which states need technical assistance, training, or programmatic guidance on the U.S. Repatriation Program. The ACF Office of Human Services Emergency Preparedness and Response (OHSEPR) will use the information gathered to enhance support services provide to state and territorial repatriation coordinators.

DESCRIPTION OF RESPONDENTS: State human and social services employees who conduct intake assessments, provide case management services, and place U.S. citizens and their dependents in state-administered human services programs after those individuals are referred to the state by ACF OHSEPR or its grantee.

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: Byron R. Mason, Deputy Director, OHSEPR_______________________________

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
(3) State, local, or tribal governments	100	20 minutes	33
Totals	100		33 hours

FEDERAL COST: The estimated annual cost to the Federal government is $1500____

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?

The Governors of U.S. states and territories have designated jurisdictional human services employees to coordinate repatriation services and operations at the state and territorial level. The Governors of U.S. states and territories have provided the contact information for these employees to OHSEPR.

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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