GenIC_1009_Request_YV TTA_1 14 16

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-1009)

TITLE OF INFORMATION COLLECTION: Youth Violence Training and Technical Assistance Satisfaction Survey

PURPOSE: To gauge whether the CDC funded Youth Violence Training and Technical Services Cooperative Agreement with the American Institute for Research (AIR) is meeting the needs of the twelve participating local health departments. This is one CDC Cooperative agreement awarded to the American Institute for Research to provide youth violence training and technical assistance to twelve local health departments. This questionnaire will assess each of the twelve local health departments’ satisfaction with the training and technical assistance being provided by AIR.

DESCRIPTION OF RESPONDENTS: There will be a total of (12) respondents, one (1) from each participating local health department. These are representatives from each of the programmatic grantees. Each representative was selected through the initiative as the point of contact (POC) and hold the title of Youth Violence Prevention Coordinator. The respondent will be the designated POC for this initiative.

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:____________Karen Angel____________________________________

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 [ X ] 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
Youth Violence Prevention Coordinators (Local Health Departments)	12	15/60	3 Hours
Totals			3 Hours

FEDERAL COST: The estimated annual cost to the Federal government is $423.00

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?

[ ] 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?

NCIPC staff will conduct 15 minute, structured phone interviews with representatives from each of the programmatic grantees. Customer satisfaction questions will be asked via telephone and given the opportunity to provide any additional comments after the survey.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[X] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

The CDC Lead project Officer and Health Scientist will be interviewing the participants.

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