Peer Group Membership Request Form OMB Application

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

TITLE OF INFORMATION COLLECTION: Children’s Bureau’s Capacity Building Collaborative, Center for States Peer Group Membership Request Form

PURPOSE: As part of the Children’s Bureau’s Capacity Building Collaborative, Center for States’ (the Center’s) implementation of service delivery and supports the Center has developed a Peer Group Membership Request Form for visitors to the Capacity Building Center for States peer group webpage (https://capacity.childwelfare.gov/states/about/peer-groups). Visitors who are interested in participating in peer groups targeted to their needs could enter information about themselves, their work, and/or their involvement in child welfare so the Center could identify relevant peer group assignments for them.

The Center’s Peer Group Membership Request Form would provide a standardized way to collect information for determining eligibility for the Center’s peer groups from individuals who would like to participate. For example, the State Foster Care Mangers Peer Group is open to state-level foster care managers. Data collected through this proposed form will contribute to the Center’s continuous quality improvement efforts to support child welfare agencies and their partners deliver services that are grounded in racial equity, engage people with lived experience and expertise in child welfare, follow evidence-based processes and practices, and keep children, youth, and families safe and thriving.

This is a request for approval by the Office of Management and Budget (OMB), under the Federal Paperwork Reduction Act of 1995, for data collection activities to be authorized under the Administration for Children and Families’ generic OMB clearance # 0970-0401. Information collection activities include delivering voluntary online surveys.

DESCRIPTION OF RESPONDENTS: Child welfare professionals including people involved in child welfare who are interested in participating in a Center peer group.

TYPE OF COLLECTION:

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [X] Other: A link to this proposed form would be available to visitors of the Center’s Peer Group Webpage. Additionally, a link to this form would also be provided (a) directly to anyone requesting to participate through other methods including by email (for direct requests) or (b) to potential participants who view the link during a virtual Center event presentation, for example.

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 primary purpose of the results is not for public dissemination.

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 and affiliation: Beth Claxon, Child Welfare Program Specialist, ACF Administration on Children, Youth and Families (ACYF)

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

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 [X] 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

Information Collection	Category of Respondent	No. of Annual Respondents	No. of Responses per Respondent	Estimated Time per Response	Burden Hours
Children’s Bureau’s Capacity Building Collaborative, Center for States Peer Group Membership Request Form	Individuals	250	1	0.033	8.25
Totals					8.3

FEDERAL COST: The estimated annual cost to the Federal government is: $263.28

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.

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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