FastTrack GenIC - Feedback Survey for Dental Health Liaison Services

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

TITLE OF INFORMATION COLLECTION: Feedback Survey for Dental Health Liaison Services 

PURPOSE AND USE: The proposed information collection will be administered to recipients of the National Center for Health, Behavioral Health, and Safety (NCHBHS) Dental Health Liaison (DHL) project. Under the DHL project, one dental hygienist from each state volunteers to help promote oral health for pregnant women and pregnant people and children enrolled in Head Start programs. The NCHBHS, which is under a cooperative agreement with the Office of Head Start, contracts with the DHL project to provide training and technical assistance to program staff on oral health, including promotion of oral health care and prevention strategies.

The proposed information collection will be administered to recipients of DHL services to solicit feedback about the services provided by the state DHL. Information will be used by NCHBHS for internal planning to inform training and technical assistance and other supports/resources in an effort to improve future service delivery. The survey will be delivered via an online survey platform.

DESCRIPTION OF RESPONDENTS: This feedback survey will be administered to recipients of DHL services. This includes Head Start and Early Head Start staff.

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: Marco Beltran, Senior Head Start Program Specialist, Office of Head Start

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 [ ] No

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

Tokens of Appreciation or Honoraria: 

Will a token of appreciation or honoraria be 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
DHL Feedback Survey	Private Sector	200	1	7 minutes	23.3

FEDERAL COST: The estimated annual cost to the Federal government is $223

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.

The link to the survey will be emailed to program contact(s) who requested services of their state DHL in the prior month.

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

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