OMB No. 0917-0036, Mini-Supporting Statement for Patient Satisfaction Survey, Crow Service Unit

Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

(OMB Control Number: 0917-0036)

T ITLE OF INFORMATION COLLECTION: Sugar Shockers Health Campaign Survey, Catawba Service Unit

PURPOSE: The information obtained from the Sugar Shockers Health Campaign (SSHC) Survey will provide data about the impact of the Catawba Service Unit’s planned three month health campaign to reduce consumption of sugar sweetened sodas and beverages. The survey will be used as a way for the Catawba Service Unit to evaluate the effectiveness of the SSHC.

DESCRIPTION OF RESPONDENTS: The SSHC Survey will be made available to Catawba Service Unit patients on a voluntary basis during a one week period prior to the beginning of the SSHC and then again for one week after the SSHC. The SSHC Survey will also be made available to tribal members at the different tribal programs (day care, head start, after school program, teen program, senior program) on a voluntary basis prior to the beginning of the SSHC and then again after the SSHC. There is no personally identifiable information on the SSHC Survey. There are 11 questions on the survey; nine are categorical questions with answer choices provided and two are opened ended questions. In addition, three pieces of demographic data are collected (age, tribe, and gender).

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: Program Evaluation

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: Heather Rhodes, RN, BSN, Community Health Nurse, Catawba Service Unit

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
Individuals – Patients at the Catawba Service Unit	50 pre- and 50 post-intervention (100 total)	5 minutes	8.33 hrs
Individuals - Tribal members enrolled in tribal programs	50 pre- and 50 post-intervention (100 total)	5 minutes	8.33 hrs
Totals	100 pre- and 100 post-intervention (200 total)	5 minutes	16.66 hrs

FEDERAL COST: The estimated annual cost to the Federal government is $133.40.

One staff person spends about 2 minutes on each survey tallying the response rates, collecting the information and reporting the totals in a reporting template. If 200 surveys are completed, this equals about 6 hours and 40 minutes. A GS 9 rate of about $20 per hour x 6.67 hours is $133.40.

Note – this survey will be conducted both pre- and post-intervention as an evaluation tool. This is a one-time intervention and so this cost is not an annual cost but a one-time cost.

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 respondent universe will include (1) the tribal members who participate in the Catawba Indian Nation tribal programs (see table below for additional info) and (2) tribal members who participate in health education activities of the SSHC provided by the Catawba Service Unit. All tribal members who participate in these educational activities will be asked to complete the survey but participation will be voluntary.

Tribal Program	Program Participants included in Respondent Universe
Little People Academy Day Care	Staff and parents
ISWA Head Start	Staff and parents
Catawba Cultural Center	Staff, program participants (children), and parents
Catawba Teen Center	Staff, program participants (children)
Catawba Senior Center	Staff, program participants (adults)

The respondent universe will also include all registered patients at the Catawba Service Unit. Patients seen at the service unit during two different one-week periods will be asked to complete the survey but participation will be voluntary. The two different one-week periods will occur prior to the health education activities as part of the SSHC (the pre-intervention surveys) and after the activities (the post-intervention surveys). These two specific one-week periods will occur approximately three months apart.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[X] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [X] No (unless a patient has low-literary skills and requires assistance)

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

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request (e.g., Comment card for soliciting feedback on xxxx).

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include a statement to that effect in your explanation. Please include how the information will be used to improve services or the program.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved. Provide the name of the individual who is the lead contact and responsible for the collection.

Personally Identifiable Information: Provide answers to the questions. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective. If you request PII, then ensure that you state the reason why it is being collected (i.e., in order to respond to inquiries from the participants).

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households; (2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost (and description) to the Federal government. Please provide a brief break down of the costs, including wages for staff utilizing OPM pay scale table. See http://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/2014/general-schedule/

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Submit all instruments, instructions, and scripts are submitted with the request.

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