Request for Approval under the “Formative Research and Tool Development” (OMB Control Number: 0920-1154)

GenIC Clearance for CDC/ATSDR

Formative Research and Tool Development

OMB No. 0920-1154

Request for GenIC Approval

Title: Caring Adults Perceptions on Teen Mental Health

Contact Information:

Hallie Carde

NCIPC/OD

803-920-0469

[email protected]

Purpose And Use of Collection

The primary goals of this project are to:

1. better understand the experiences of girls and nonbinary adolescents (ages 13-17) seeking and accessing mental health care in rural America

2. inform opportunities for this population for public health interventions and upstream prevention at CDC

Description of Respondents

The population of focus for the semi-structured interviews and focus group sessions are adults that mentor or support those adolescents with programs and services.

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [] Yes [ X ] No

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

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No

Gifts or Payments

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [X] Yes [ ] No -- Each participant will receive a $50 Visa gift card per completed session.

Burden Hours

Category of Respondent	Form Name	No. of Respondents	Participation Time (Hours)	Burden (Hours)
Adult Mentor Participants	Emails (Attachment 1)	20	15/60	5
	Screening Survey (Attachment 2)	20	10/60	3
	Adult Mentor Consent Form (Attachment 3)	10	10/60	2
	Interview Discussion Guide (Attachment 4)	10	1	10
	Focus Group Session Discussion Guide (Attachment 5)	5	1.5	8
Totals				28

Federal Cost: The estimated annual cost to the Federal government is $15,760.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

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

Recruitment for the interviews and focus will be conducted via convenience sampling through partnerships with local community-based organizations, local youth-serving and tribal organizations:

• YMCA of Southeastern North Carolina

• YMCA Mountain States Alliance (MT)

• Family YMCA of Los Alamos, New Mexico

• North Carolina Native American Youth Organization

• Time Out Youth

Interviews will take 60 minutes to complete while focus groups will take 90 minutes to complete. There is no cost to participants beyond the participation burden time.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[X] Other - Virtually and In-Person

2. Will interviewers or facilitators be used? [X] Yes [ ] No

Restricted Use/Any User (No encryption)

Restricted Use/Any User (No encryption)