OMB No. 0917-0036, Mini-Supporting Statement for IHS CHR NET Plenary Evaluation Form

Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

(OMB Control Number: 0917-0036)

TITLE OF INFORMATION COLLECTION: OMB Form No. 0917-0036: Indian Health Service (IHS) Community Health Representatives (CHR) National Education Training (NET) Evaluation

PURPOSE: This collection of information via a training evaluation survey is necessary to enable IHS to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improve continuing education training services mandated by the Indian Health Care Improvement Act as amended. The information collected from participants is voluntary and will help ensure users have an effective, efficient and satisfying CHR training experience. IHS will also use their responses to improve future trainings. Personally identifiable information (PII) is provided voluntarily by individuals who want to have follow-up contact with IHS. IHS will comply with applicable requirements, restrictions and prohibitions of the Privacy Act and other privacy and confidentiality laws that govern the agency’s collection, retention, use and/or disclosure of such PII.

DESCRIPTION OF RESPONDENTS: Individuals (Indian Health Service CHR employees, Tribal and Urban CHRs, other customers and stakeholders) who are participants in a CHR NET biannual national continuing education training.

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: Celissa Stephens

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

Personally Identifiable Information:

7. Is personally identifiable information (PII) collected? [ ] No [X ] Yes – only to the extent the individual voluntarily provides contact information for a requested response from IHS.

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

9. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ X ] No – Does not apply.

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
Indian Health Service employees	25	5/60 minutes/hour	2 hours per year
Tribal and Urban CHRs	250	5/60 minutes/hour	21 hours per year
Other customers and stakeholders	50	5/60 minutes/hour	4 hours per year
Totals	325		27 hours per year

FEDERAL COST: The estimated annual cost to the Federal government is $120.

These costs are comprised of the following: Implementing survey online, administering, reviewing and developing collective recommendations from those results. Cost breakdown:

• Two employees spend 30 minutes costing $30 each (based on $60/hour) to review, implement online and maintain survey. Cost $60

• Two employees spend 30 minutes at $30 each (based on $60/hour) to review survey responses and develop collective recommendations. Cost $60

Total Cost - $120

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?

This is a voluntary on-line survey which is offered to participants at the CHR NET.

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.

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Submit all instruments, instructions, and scripts are submitted with the request.

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