Public Health AmeriCorps TTA Questions Submission Form

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 3045-0137)

TITLE OF INFORMATION COLLECTION:

Process and Implementation Evaluation of Public Health AmeriCorps:

Technical Assistance and Training Needs Form

PURPOSE:

AmeriCorps (formerly the Corporation for National and Community Service) requests approval from the Office of Management and Budget (OMB) to gather information from the inaugural cohort of 82 Public Health AmeriCorps grantees as part of its process and implementation evaluation of Public Health AmeriCorps under the “Generic Clearance for the Collection of Routine Customer Feedback (OMB Control Number: 3045-0137).” The current application describes the data collection to assess challenges grantees have faced or are facing in implementing their program. The proposed data collection will gather information on successes, challenges, and the type of training that will support Public Health AmeriCorps members succeed at their service site, and in the communities that they serve. AmeriCorps will use the responses to inform discussion on the allocation of programmatic resources for member training as well as technical assistance support to grantees for fiscal year 2023. Two accompanying application includes a survey and three focus groups with five participants per focus group.

Public Health AmeriCorps is a partnership between AmeriCorps and the Centers for Disease Control and Prevention (CDC) with two main goals:

1. Address public health needs of local communities by providing support in state and local public health settings and advancing equitable health outcomes for underserved communities.

2. Create pathways to public health-related careers through onsite experience and training and recruiting AmeriCorps members who reflect the communities they serve.

DESCRIPTION OF RESPONDENTS:

The respondents are the 82 inaugural cohort Public Health AmeriCorps partners who have received funding to implement a program that addresses public health needs of local communities and advance equitable health outcomes for underserved communities; and to create pathways for the members that serve to enter the public-health workforce.

Partners are nonprofit organizations, federally recognized Indian tribes, public, private, tribal, or faith-based nonprofit organizations as well as local or state agencies.

TYPE OF COLLECTION: (Check one)

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

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

[ ] Focus Group [X] Other: Technical Assistance and Training Needs

Form

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: Nicole Jones, COR____

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

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

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	Burden
1 representative from each funded grantee	82	15 minutes	20.5 hours
Totals	82	15 minutes	20.5 hours

FEDERAL COST: The estimated annual cost to the Federal government is $9,500.00.

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?

There are 82 Public Health AmeriCorps grantees. AmeriCorps will contact all 82 grantees for this data collection.

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

[ X ] Other, Explain: Online completion of form

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”

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 one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

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:

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.

Participation Time: 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)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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 the sampling plan 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.

Submit all instruments, instructions, and scripts are submitted with the request.

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