FastTrack GenIC - Tribal MIECHV Program Training and Technical Assistance Immediate Feedback Form .

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

TITLE OF INFORMATION COLLECTION: Tribal Maternal, Infant, and Early Childhood Home Visiting (TMIECHV) Program Training and Technical Assistance Immediate Feedback Form .

PURPOSE: The Administration for Children and Families (ACF) Office of Early Childhood Development Tribal Maternal, Infant, and Early Childhood Home Visiting (TMIECHV) Program funds a contract with Programmatic Assistance for Tribal Home Visiting (PATH) to provide Technical Assistance (TA) to TMIECHV funding recipients. ACF collects feedback from grant recipients about their satisfaction to inform the planning of training and TA delivered through webinars, peer calls, workshops, community of learnings, and similar events. The information is intended for internal use and planning to help ensure that ACF provides TMIECHV grant recipients with effective and efficient support.

DESCRIPTION OF RESPONDENTS: The TMIECHV program provides grants to tribal organizations to develop, implement, and evaluate home visiting programs in American Indian and Alaska Native communities. The program is funded by a six percent set-aside from the larger MIECHV program. TMIECHV grants are awarded to Indian tribes, consortia of tribes, tribal organizations, and urban Indian organizations. Grantee team members such as directors, supervisors, data collection personnel, evaluators, and home visitors attend training and TA events.

TYPE OF COLLECTION:

[ ] 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 primary purpose of the results is not for public dissemination.

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 and affiliation:__Anne Bergan, ACF Tribal Early Chilhood Development Division_____

To assist review, please provide answers to the following questions:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [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? [X] No

BURDEN HOURS

Information Collection	Category of Respondent	No. of Respondents	No. of Responses per Respondent	Estimated Time per Response	Burden Hours
Tribal MIECHV Program Training and Technical Assistance Immediate Feedback Form	Individuals	125	3	2 minutes	12.5 hours

FEDERAL COST: The estimated annual cost to the Federal government is $ 1,350.00_based on labor hours by the contractor to collect and analize submissions.

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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?

Participants of training and TA events are current and future grantees who received a TMIECHV grant from ACF to implement evidence-based home visiting services. Grants are generally awarded for five years. All grantee participants of training and TA events are invited to complete the Immediate Feedback Form after each training and TA occurrence.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[X] Other, Explain: Survey App or Paper Copy

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

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

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