GENIC Template with Project Description and Burden Estimate

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
The information gathered will only be used
internally to CDC.
[ X ] Yes [ ] No
Data is qualitative in nature and not generalizable
to people from whom data was not collected.
[ X ] Yes [ ] No

Column B
Information gathered will be publicly released or
published.
[ ] Yes [ X ] No
Employs quantitative study design (e.g. those that
rely on probability design or experimental
methods)
[ ] Yes [ X ] No
Sensitive questions will be asked (e.g. sexual
orientation, gender identity).
[ ] Yes [ X ] No

There are no sensitive questions within this
collection (e.g. sexual orientation, gender
identity).
[ X ] Yes [ ] No
Collection does not raise issues of concern to any
other Federal agencies.
[ X ] Yes [ ] No
Data collection is focused on determining ways to
improve delivery of services to customers of a
current CDC program.
[ X ] Yes [ ] No

Other Federal agencies may have equities or
concerns regarding this collection.
[ ] Yes [ X ] 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.

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TITLE OF INFORMATION COLLECTION:
Evaluators’ Network, Member Survey
PURPOSE:
The CDC Office on Smoking and Health (OSH) Evaluators’ Network
(“Network”) serves to support surveillance and evaluation technical assistance and
capacity building for National Tobacco Control Program (NTCP) grantees. The
Network provides a venue for the OSH surveillance and evaluation teams to
provide NTCP grantees with training, tools, and resources in a consistent manner
across states to improve their work and capacity in tobacco control and evaluation
efforts. It also supports peer-to-peer learning by fostering peer engagement,
collaboration, and information sharing.
The services provided through the Network include trainings, webinars,
newsletters, and a networking website that serves to foster peer engagement and an
online community of practice. While each service offered serves a distinct function
and offers different resources, they are also designed to complement each other and
reinforce knowledge building. The Network is open to NTCP surveillance and
evaluation (S&E) staff from all 50 states and the District of Columbia, as well as
funded territories, national networks, contractors, and other partners working with
tobacco control programs.
This proposal seeks to survey NTCP surveillance and evaluation staff on their
satisfaction and use of Evaluators’ Network services. We will use information
gathered from the survey to continue to build the Network and inform
improvements to Network webinars, newsletters, networking website. Without this
feedback, OSH will not have timely information to make changes to the Network
services to meet customer needs better. The survey is anonymous, solely on a
volunteer basis, and participation in the Evaluators’ Network Member Survey
suggesting points of improvement does not in any way affect CDC funding of
NTCP recipients. Users will complete the survey using an online platform.

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DESCRIPTION OF RESPONDENTS:
Participation in the Evaluators’ Network Member Survey is voluntary. One
hundred and ninety (190) representatives from CDC funded tobacco control
programs who participate in the Evaluators’ Network will be invited to participate
in the survey. This group consists of tobacco control program surveillance and
evaluation staff funded by CDC funding opportunities acting in their official
capacity.

TYPE OF COLLECTION: (Check one)
Instruction: Please sparingly use the Other category

[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[ X ] Customer Satisfaction Survey
[ ] Small Discussion 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: Briana Oliver, ORISE Fellow, National Center for Chronic Disease Prevention and
Health Promotion, Office on Smoking and Health/Epidemiology Branch
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

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BURDEN HOURS
Category of Respondent
State, local, or tribal governments

No. of
Respondents
190

Participation Time Burden
10 MINUTES

32 HOURS

Totals

FEDERAL COST: The estimated annual cost to the Federal government is $0.
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 sampling cohort is defined by the membership of the Evaluators’ Network, in that,
there are a total of 190 potential respondents. All (100%) of the Network members are
invited to participate in the survey.

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.

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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:

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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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