Fast Track Memo_CERV Net

Request for Approval under the Voluntary Partner Surveys to Implement Executive Order 12862: 0915-0212)

TITLE OF INFORMATION COLLECTION: Federal Cervical Cancer Collaborative (FCCC) CERV-Net Evaluation

PURPOSE: To assess the quality and effectiveness of the FCCC Project ECHO remote learning series, “CERV-Net,” and to assess collaboration, engagement, and peer learning of Project ECHO participants. Project ECHO (Extension for Community Healthcare Outcomes) is a collaborative model of medical education and care management that helps clinicians provide expert-level care.

DESCRIPTION OF RESPONDENTS: Health care providers working in safety-net settings of care who are participants of the FCCC CERV-Net Project ECHO remote learning series.

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: Jane Segebrecht

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

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 (Hours)	Burden Hours Total
FCCC CERV-Net Participants	48	0.75	36
Totals	48	0.75	36

FEDERAL COST:

The estimated annual cost to the federal government of this evaluation is $104,961.60 for external contractor staff to collect and manage the data and develop an interim process evaluation report, final process evaluation report, and an outcome evaluation report..

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 sampling frame includes all 48 participants of the Federal Cervical Cancer Collaborative CERV-Net remote telelearning series. Participants will be recruited and retained in the learning series by the contractor.

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.