Fast Track Submission Template

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

TITLE OF INFORMATION COLLECTION: Tribal Home Visiting Evaluation Institute (TEI) Technical Assistance (TA) Satisfaction Survey

PURPOSE:

To collect feedback from Tribal Maternal, Infant, and Early Childhood Home Visiting (Tribal MIECHV) awardees who received technical assistance related to performance measurement, evaluation, continuous quality improvement (CQI), data systems, and dissemination through the Tribal Home Visiting Evaluation Institute 3 (TEI 3) contract. The TEI 3 project provides support and technical assistance (TA) to Tribal MIECHV awardees around planning and implementing evaluations, collecting and reporting performance measurement data, and conducting CQI projects. Feedback will be elicited from awardees and will be used to improve and tailor future TA provision.

DESCRIPTION OF RESPONDENTS:

The respondents are members of Tribal MIECHV grantee teams who have received TA from TEI 3. The respondents fill various roles on the Tribal MIECHV teams including program directors, program coordinators, evaluators, and data analysts.

TYPE OF COLLECTION:

[ ] 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 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:_Rebecca Hjelm, Office of Planning, Research, and Evaluation __

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

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 [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 Respondents	No. of Responses per Respondent	Estimated Time per Response	Burden Hours
	Tribal MIECHV grantee teams (1 respondent per team)	22	1	10 minutes	3.66
Totals		22	1	10	3.66

FEDERAL COST: The estimated annual cost to the Federal government is $4900_________

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 programmatic technical assistance providers for the Tribal MIECHV grantees maintains a contact list of grantee team members. This list includes those who serve in the targeted roles (program director, program coordinator, evaluator, data analyst). The list includes all grantees from the 4 cohorts currently funded by ACF. This survey will be sent to 3 of the 4 cohorts, as technical assistance from TEI has not been provided to the 4^th cohort at this time. The targeted cohorts include: Development and Implementation Grantees Cohort 1, Implementation and Expansion Grantees Cohort 1, and Implementation and Expansion Grantees Cohort 2. The survey will be sent to team members from each grantee team by their TEI liaison and teams will be asked to complete one survey per grantee site.

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 Routine Customer Feedback”

Information collections approved under this Generic must display the required Paperwork Reduction Act information, which includes the following:

1. On the upper right of the first page: OMB Control Number: 0970-0401, Expiration Date: June 30, 2024.

2. At the bottom of the first page, include the following language. For red text in brackets, choose the best option and delete the other bracketed option(s). Replace highlighted areas with content specific to your collection.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: ACF is gathering information to better understand Tribal MIECHV grantees’ experience of technical assistance. The purpose of this information collection is to improve technical assistance offerings. Public reporting burden for this collection of information is estimated to average ten minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. Agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0401 and the expiration date is 06/30/2024. If you have any comments on this collection of information, please contact Erica Roberts; [email protected].

Submit all instruments, instructions, and scripts with the request. Each instrument should be an individual file and should be titled to match the title in the burden table.

The following provides information to fill out the form categories in this document.

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 the appropriate box(es) for the proposed information collection.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved. On the Name line, include the name, program office, and role of the federal point of contact.

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:

Information Collection: Provide the title of the information collection(s) (ex. Grantee meeting feedback form). Please make the title in the burden table and the title of the corresponding file match.

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.

No. of Responses per Respondent: Provide the number of times each respondent will respond to an information collection. This is usually just once for requests under this generic, but there may be instances where a collection requires more than one response per respondent.

Estimated Time per Response: 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). This can be in minutes or hours.

Burden: Multiply: (No. of Respondents) x (No. of Responses per Respondent) x (Estimated Time per Response). If you provided an estimated time per response in minutes, divide the total product by 60 to provide a burden estimate in hours.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government. This should include only costs directly related to this specific data collection.

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 a brief description of the sampling plan within this document or if the plan is more complex, you can include a description 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.

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