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: ELI Fellowship End of Year Survey

PURPOSE:

The Centers for Disease Control and Prevention (CDC) seeks to obtain Office of Management and Budget (OMB) approval to collect annual feedback for the CDC E-learning Institute Fellowship (ELI) hosted between January – June each year. ELI is held on an annual basis for the primary purpose of providing a training experience of designing and developing e-learning for public health training professionals. Overall, ELI’s goals are to provide an opportunity to implement e-learning best practices, increase collaboration by strengthening the public health training professional network, and improve the quality of public health training available nationwide. CDC is requesting OMB approval to collect feedback to ensure the ELI is meeting its goals and the needs of fellowship participants and mentors. The ELI program intends to use the results of this data collection to improve the logistics, communication, and quality of ELI curriculum and live sessions when planning future cohorts.

DESCRIPTION OF RESPONDENTS:

Respondents to the ELI Fellow End of Year Evaluation Survey (Attachment 1, Survey in MSWord and Attachment 2, Survey Screenshots) will be ELI fellows. Fellows come from a variety of fields, and include local, state, territorial and tribal public health training professionals, and may include persons from public health agencies in Canada. Respondents to the ELI Mentor End of Year Evaluation Survey (Attachment 3, Survey in MSWord and Attachment 4, Survey Screenshots) will be ELI mentors. Mentors are primarily CDC employees, but may also include instructional design experts from local, state, territorial, or tribal public health agencies. No personally identifiable information (PII) will be collected; however, if respondents provide PII, it will not be retained.

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: Britney Johnson

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 [X] 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

The ELI Fellow End of Year Survey (Attachment 1) is a web-based survey with 13 questions. Respondents will take approximately 8 minutes to complete the survey through SurveyMonkey. This will be a one-time survey, distributed upon Fellow completion of the six-month program.

The ELI Mentor End of Year Survey (Attachment 3) is a web-based survey with 8 questions. Respondents will take approximately 5 minutes to complete the survey through SurveyMonkey. This will be a one-time survey, distributed to Mentors upon at the end of the six-month program.

Category of Respondent	No. of Respondents	Participation Time	Burden
State, Local, or Tribal Governments (ELI Fellow End of Year Survey)	20	8/60	3 hours
State, Local, or Tribal Governments (ELI Mentor End of Year Survey)	10	5/60	1 hours
Totals			4 hours

FEDERAL COST: The estimated annual cost to the Federal government is $1,891.52. This is based on pay for two positions. The first position estimate is based on the time required for one senior CDC scientist (GS-13) to consult and one contractor, (pay grade to be equivalent to GS-12) to implement the data, conduct data analysis, and report on findings.

Staff or Contractor	Hours	Average Hourly Rate	Cost
Contractor (GS-12 equivalent): survey design, create web-based survey, implementation, analysis, and reporting	40	40.13	1605.20
FTE (GS-13): Provide oversight and guidance on data analysis. Provide feedback on the final report.	6	47.72	286.32
Totals	46		1891.52

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 ELI Fellowship End of Year Survey will be administered as a web-based survey to the pre-defined list of participating fellows and mentors for the annual cohort. Respondents will be given 2 weeks to respond to the survey. A reminder email (Attachment 5, Reminder Email) will be sent twice: one at the beginning of week 2 and one on the day that the survey closes. Respondents will have to complete the survey in one sitting. Respondents cannot return to edit or complete the survey and the survey does not track individual responses.

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.

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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