Att_Generic_Clearance_OMB_Template_Instrument_NEEDS_ASSESSMENTS 8

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 1800-0011)

TITLE OF INFORMATION COLLECTION:

SSS TA Needs Assessment Template

PURPOSE:

The Safe and Supportive Schools Technical Assistance Center believes that it is important to determine the needs of grantees to provide effective services and products. The data collected will provide the information for planning content, product development and events in order to meet their needs in meeting program requirements.

DESCRIPTION OF RESPONDENTS:

Audiences vary and are comprised of from 50-100 people. Each will be given the opportunity to complete a needs assessment template. SSS TA requests such information at the start of each fiscal year for planning purposes.

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: Needs Assessment__

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: Sandra Williamson, Director, National Center on Safe Supportive Learning Environments, swilliamson@air.org

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, 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? [ ] Yes [X] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Campus Health Administrators	150	15 mins	37.5 hours

FEDERAL COST: The estimated annual cost to the Federal government is __$0_________

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 is a list of designated federal grantees, who will provide the information.

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

3