Fast Track Submission Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0970-0401)

TITLE OF INFORMATION COLLECTION: Youth Suicide Prevention Pre and Post Survey

PURPOSE: The purpose of the survey is to assess knowledge and perceptions of youth suicide prevention before and after completing Mental Health America of Greater Houston’s Center for School Behavioral Health (CSBH) Youth Suicide Prevention Module. This information is used to measure impact and to guide quality improvement efforts. Individual responses are confidential. This information is seen only by the CSBH Evaluation team. Survey results are de-identified (name and contact information are removed) and aggregated before sharing. The survey will be given to attendees of the SRAE topical training which will be conducted in March 2023.

Youth Suicide Prevention Pre-Survey (Attachment A)

Youth Suicide Prevention Post-Survey (Attachment B)

The survey includes multiple choice, true and false and open-ended questions and is estimated to take no longer than 5 minutes to complete.

The purpose of the pre-survey quiz (attachment A) and post-survey (attachment B) is to assess achievement of learning goals. The purpose of the satisfaction survey is to assess participation satisfaction with the training content, delivery method and trainer’s capacity.

The surveys be administered in-person in a paper-based format. Participants will receive the pre-survey (Attachment A) prior to the training and post-survey (Attachment B) at the end of the training. The quizzes include multiple choice questions and are estimated to take no longer than 10 minutes to complete.

In lieu of adding the paperwork reduction action statement to the survey instruments, a PowerPoint slide with information to note the purpose of the data collection, its voluntary nature, the paperwork reduction act and corresponding control number will be shown to participants prior to being asked to complete any surveys.

DESCRIPTION OF RESPONDENTS: Respondents are all SRAE grantees (Title V State, Title V Competitive, and GD-SRAE).

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: Knowledge 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:__Corey Palmer, Program Manager, Adolescent Pregnancy Prevention Program

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 Not applicable

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No Not applicable

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [ X ] No

BURDEN HOURS

Estimated Annual Reporting Burden
Type of Collection	No. of Expected Respondents	Frequency per Response	Hours per Response	Total Hours
SRAE Grantee Topical Training Survey	90	1	5 min (0.08 hours)	0.08
Total estimated burden hours

FEDERAL COST: The estimated cost to the Federal government is $__3,666______

Item/Activity	Details	$ Amount
FYSB oversight of contractor and project	1% of FTE: GS-13 Program Specialist	$1,000
Contractor oversight of trainers	Labor hours (1.0% of FTE for contractor staff)	$2,666
Total		$_5,000

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?

Attendees of the in-person topical training will be asked to complete the survey. The training has capacity for up to 90 SRAE grantees.

Administration of the Instrument

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

[X] Web-based

[ ] Telephone

[ X ] In-person

[ ] Mail

[ ] Other, Explain

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

Please make sure that all instruments, instructions, and scripts are submitted with the request.

The survey instruments are attached along with this form as Attachment A and B.

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