Trainee Ambassador Group Survey

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: Trainee Ambassador Group Survey

PURPOSE: To gather information from current and former trainees from MCHB-funded training programs to determine the professional development needs of the trainee network and future MCH workforce.

DESCRIPTION OF RESPONDENTS: Current and former trainees from MCHB-funded training programs (LEND, DBP, LEAH, PPC, Nutrition, Catalyst, LEAP, CoE)

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:

Bridget Kerner (Bkerner@hrsa.gov)

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
Current trainees	60	15 Minutes	15
Former trainees	30	15 Minutes	7.5
Totals	90	15 Minutes	22.5

FEDERAL COST:

The estimated annual cost to the federal government is $554.60, which includes staff time of 10 hours at the GS-13 level in project management and oversight.

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?

We will recruit potential respondents from our trainee listserv and through our project officers, who will disseminate via their grantees. All respondents who volunteer to complete the survey will be given the opportunity to do so.

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.