Fast Track GenIC Submission Form - Screenings 2 Services Challenge: Feedback Survey

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

T ITLE OF INFORMATION COLLECTION: Screenings 2 Services Challenge: Feedback Survey

PURPOSE: The Administration for Children and Families (ACF) Office of Head Start (OHS) and Health Resources & Services Administration (HRSA) Bureau of Primary Health Care (BPHC) will launch the Screenings 2 Services Challenge in summer 2021 to invite applicants to first propose and then develop innovative approaches to help children receive health, educational, and social services based on identified needs from developmental screenings, with a goal of promoting children’s health and wellbeing. This proposed information collection will request feedback from HRSA Health Centers and Head Start stakeholders via social media to inform the Screenings 2 Services Prize Challenge. Before the launch of this challenge, this customer feedback survey will provide timely feedback from potential participants in an efficient manner to improve the delivery of the challenge. This is the sole source of systematically collected satisfaction data from potential participants of this challenge. This feedback survey will gauge respondents’ level of interest in the challenge model and the preferred delivery method of the challenge outcomes. Responses to this survey will be used to inform planning and improvement of the delivery of the challenge during the summer.

DESCRIPTION OF RESPONDENTS: HRSA Health Centers and Head Start stakeholders. This includes Head Start/Early Head Start staff, early childhood education providers, staff in HRSA Health Centers, and other organizations working with early childhood programs.

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: _____ Beth Caron, Social Science Analyst, Office of Head Start____________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [X] Yes [] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [] Yes [X] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [] Yes [] No

PII Collected: Respondents are given the option to provide their name and email address if they would like to receive updates about the future prize challenge. These are optional fields.

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
HRSA Health Centers and Head Start stakeholders	300	5 minutes	25 hours
Totals	300		25 hrs

FEDERAL COST: The estimated annual cost to the Federal government is $500.

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 survey will be sent out to HRSA health centers and via Head Start social media channels.

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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