Original Generic IC Request

Request for Approval under the “Voluntary Partner Surveys to Implement Executive Order 12862/Questionnaire and Data Collection Testing, Evaluation, and Research for the Health Resources and Services Administration” (OMB Control Number: 0915-0212/0915-0379)

TITLE OF INFORMATION COLLECTION: Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program Site Visit Compliance Review Awardee Feedback Form

PURPOSE: The purpose of this information collection request is to assess awardees’ satisfaction with the MIECHV Program’s site visit process. HRSA conducts in average one site visit compliance review with each MIECHV awardee every three years through a contractor as a part of oversight and technical assistance activities to support the implementation of the MIECHV Program. The feedback form will collect timely awardee feedback on their experiences of the site visit process from pre-visit planning to post-visit activities. By collecting this information, HRSA is able to assess the performance of the site visit contractor and promote accountability to high-quality performance. Collected information will also be used to inform a continuous quality improvement framework to refine the site visit compliance review process. Data analysis will include basic descriptive statistics and qualitative analysis of responses.

DESCRIPTION OF RESPONDENTS: MIECHV awardee staff who participate in the site visit compliance reviews.

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: Soohyun Kim, Supervisory Public Health Analyst

Division of Home Visiting and Early Childhood Systems

Maternal and Child Health Bureau

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 Hours Total
MIECHV Awardee Participants in Site Visit Compliance Reviews	270	0.25	67.5
Totals			67.5

FEDERAL COST:

The estimated annual cost to the federal government is $81,858, which includes $2,200 in staff hours (40 hours at the GS 13, Step 2 level) in project management and contract oversight and $79,658 for in contract costs (estimated at 1% of the total contract cost) for survey administration and data analysis.

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?

The site visit contractor will have a list of awardee staff that participate in their site visit compliance review. HRSA anticipates that there will be an average of 18 site visits per year and that each site visit will have up to 15 participants. There will be no sampling, all the participants will receive the feedback form.

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

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