GenIC Request Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-1050)

Instruction: This form should be completed by the primary contact person from the Program sponsoring the collection.

DETERMINE IF YOUR COLLECTION IS APPROPRIATE FOR THIS GENERIC CLEARANCE MECHANISM:

Instruction: Before completing and submitting this form, determine first if the proposed collection is consistent with the scope of the Collection of Routine Customer Feedback generic clearance mechanism. To determine the appropriateness of using the Collection of Routine Customer Feedback generic clearance mechanism, complete the checklist below.

If you select “yes” to all criteria in Column A, the Collection of Routine Customer Feedback generic clearance mechanism can be used. If you select “yes” to any criterion in Column B, the Collection of Routine Customer Feedback generic clearance mechanism cannot be used.

Column A	Column B
The information gathered will only be used internally to CDC. [X] Yes [ ] No	Information gathered will be publicly released or published. [ ] Yes [X] No
Data is qualitative in nature and not generalizable to people from whom data was not collected. [X] Yes [ ] No	Employs quantitative study design (e.g. those that rely on probability design or experimental methods) [ ] Yes [X] No
There are no sensitive questions within this collection (e.g. sexual orientation, gender identity). [X] Yes [ ] No	Sensitive questions will be asked (e.g. sexual orientation, gender identity). [ ] Yes [X] No
Collection does not raise issues of concern to any other Federal agencies. [X] Yes [ ] No	Other Federal agencies may have equities or concerns regarding this collection. [ ] Yes [X] No
Data collection is focused on determining ways to improve delivery of services to customers of a current CDC program. [X] Yes [ ] No	Data will be used to inform programmatic or budgetary decisions, for the purpose of program evaluation, for surveillance, for program needs assessment, or for research. [ ] Yes [X] No
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. [X] Yes [ ] No

Did you select “Yes” to all criteria in Column A?

If yes, the Collection of Routine Customer Feedback generic clearance mechanism may be appropriate for your investigation. You may proceed with this form.

Did you select “Yes” to any criterion in Column B?

If yes, the Collection of Routine Customer Feedback generic clearance mechanism is NOT appropriate for your investigation. Stop completing this form now.

TITLE OF INFORMATION COLLECTION: Strategic Scholars Program Participant Feedback Survey

PURPOSE:

The Center for State, Tribal, Local, and Territorial Support (CSTLTS)’s Performance Development, Evaluation, and Training Branch (PDETB) seeks to obtain program participant feedback on its Strategic Scholars Program. To obtain feedback related to attendees’ satisfaction with and reaction to participation in the Strategic Scholars Program, PDETB proposes a low-burden, end-of-cohort reaction survey (up to 22 questions). The survey will be administered at the conclusion of the May-October 2022 cohort and will capture respondents’ reactions to overall program structure and to specific program offerings, including web-based training, group learning sessions, team coaching, and applied team projects. Results will be used to refine the program model and improve its delivery for future cohorts of scholars.

DESCRIPTION OF RESPONDENTS:

The respondent universe includes all participants in the May-October 2022 cohort of the CDC-sponsored Strategic Scholars Program (N=40). All current participants in the Strategic Scholars Program will receive an invitation to complete the web-based survey (see Attachment A—SSP Instrument Word Version and Attachment B—SSP Instrument Web Version). The instrument will be used to gather information from program participants regarding their experience in the current cohort of the Strategic Scholars Program.

TYPE OF COLLECTION: (Check one)

Instruction: Please sparingly use the Other category

[ ] 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.

Name: Brittany Argotsinger, MPH_______________________________________________

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, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Applicable, has a System or Records Notice 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

If Yes: Please describe the incentive. If amounts are outside of customary incentives, please also provide a justification

BURDEN HOURS

All 40 local and territorial health department staff who are current participants in the Strategic Scholars Program will receive an invitation to complete the survey. The end-of-cohort reaction survey includes up to 22 questions: 19 questions are closed-ended (multiple choice) and three questions are open-ended. The survey includes conditional branching, therefore the actual number of items to which participants respond will vary. Respondents will complete the survey using SurveyMonkey© web-based survey software.

To estimate the burden (hours), CDC piloted the survey with internal CDC staff to calculate the average length of time to complete the survey, including reading the instructions. Based on the results of the pilot, the average time to complete the end-of-training survey is around 6 minutes (6m:22s). The total estimated burden (hours) for 40 respondents is reflected in the table below. There are no other costs to the respondent.

Category of Respondent	No. of Respondents	Participation Time	Burden
Local health department participants	38	6/60	3.8
State health department participants	0	6/60	0.0
Territory health agency participants	2	6/60	0.2
Totals	40		4.0

FEDERAL COST: The estimated annual cost to the Federal government is $5,051.60. There are no equipment or overhead costs. Costs to the federal government are limited to less than 0.1 FTE salary for CDC staffing. CDC staff will lead the development, programming, and pilot testing of the survey instrument and manage all aspects of data cleaning, analysis, and reporting.

Estimated Annualized Cost to the Federal Government

Staff (FTE)	Estimated Hours	Hourly Rate	Total Cost
Health Scientist (GS-13) OMB package development, pilot testing, survey programming, data management (cleaning, analysis, reporting)	80	$49.31/hour	$3,944.80
Health Scientist (GS-9) Support for data cleaning, analysis, and reporting	40	$27.67/hour	$1,106.80

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 Yes: Please provide a description of both below (or attach the sampling plan)

If No: Please provide a description of how you plan to identify your potential group of respondents and how you will select them or ask them to self-select/volunteer

The respondent universe includes all participants in the May-October 2022 cohort of the CDC-sponsored Strategic Scholars Program (N=40). Participants will first receive the link to the survey via Zoom chat (see Attachment C – Zoom Chat Survey Post) during the final required program session. In addition, all participants will receive an invitation to complete the survey (see Attachment D – Survey Invitation Email) at their email address provided in their team’s application to participate.

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

Data will be collected via web-based survey and respondents will be recruited through multiple notifications (see Attachments C – F). Each notification will explain:

• The purpose of the data collection, and why their participation is important

• Instructions for participating

• Method to safeguard their responses

• That participation is voluntary

• The expected time to complete the instrument

• Contact information for the project team

Participants will have two weeks to complete the survey. After the initial email invitation to participate, a reminder email will be sent at one week prior to closing the survey (see Attachment E – Reminder Email) and the day before the survey closes (see Attachment F – Final Reminder Email). Those who do not respond within 14 business days of the initial email invitation will be considered non-responders.

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

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 concise 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 this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a concise 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. The ‘Other’ category should be used only in the contexts in which the provided categories cannot reasonably apply.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions.

Gifts or Payments: As a general matter, incentives are not appropriate for customer service collections; however, incentives may be appropriate for focus groups or in-depth usability studies, especially when participants must travel to a site to participate. In the latter circumstance, the incentive should include travel costs. Customary incentives for focus groups in the Federal government are $40 for a one-hour interview and $75 for a 90-minute focus group. If you answer yes to the question, please describe the incentive and provide a justification for amounts other than those cited above; justifications should be limited to Federal studies of a similar design and subpopulation.

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.

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 to the Federal government.

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.

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

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