Generic Template

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

TITLE OF INFORMATION COLLECTION:
FY2018 OSHS Grantee Needs Assessment Form

PURPOSE:

This needs assessment will help the U.S. Department of Education and the National Center on Safe Supportive Learning Environments (NCSSLE) identify the needs of grantees (see respondents below) supported by the NCSSLE team. Delivered annually, the responses to this needs assessment will shape technical assistance supports offered through the fiscal year. Over time, the data can also be used to indicate progress or shifting concerns among grantees based on where they are in their grant cycle.

DESCRIPTION OF RESPONDENTS:

This form will be distributed to two of the grantee cohorts supported by the NCSSLE team – Project Prevent (P2) and Promoting Student Resilience (PSR). NCSSLE also supports Elementary and Secondary School Counselor (ESSC) grantees; however, because of the limited scope of TA that can be delivered to this group, they will receive an abbreviated form consistent with OMB approved forms of the past. This form may be adapted for use with the Student Support and Academic Enrichment (SSAE) grantees that NCSSLE is anticipated to support; however, there are no plans for them to use this form at this time.

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: Online needs assessment survey

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: Greta Colombi

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 [ ] 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
State, local, or tribal governments	25	30 minutes	12 hours
Totals

FEDERAL COST: The estimated annual cost to the Federal government is $67,500. There is no direct cost to respondents.

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 22 P2 grantees and 3 PSR grantees. Each grantee has a Project Director/Manager whose contact information is maintained by their respective technical assistance specialist. These 25 individuals are to whom the survey will be distributed.

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