GenIC Request Template - 0920-1050

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.

Note: Use OMB format when asking race/ethnicity as well as gender questions.

TITLE OF INFORMATION COLLECTION: Violence Prevention Technical Assistance Center Participant Feedback Forms

PURPOSE:

Violence is an urgent public health problem. It affects people in all stages of life and can lead to a lifetime of physical, emotional, and economic problems. The Division of Violence Prevention (DVP) at the National Center for Injury Prevention and Control (NCIPC) at the Centers for Disease Control and Prevention (CDC) is committed to preventing violence so that everyone can be safe and healthy.

CDC/NCIPC houses the Violence Prevention Technical Assistance Center (VPTAC), which provides training and technical assistance (TTA) to all organizations funded by CDC/NCIPC to prevent interpersonal violence, including child abuse and neglect, youth violence, intimate partner violence, sexual violence, and associated adverse childhood experiences.

VPTAC collects information regarding the quality, satisfaction, and perceived usefulness of group training and technical assistance (TTA) events. The purpose of this data collection is to understand recipients’ satisfaction with TTA events, including their perceptions of the quality and usefulness of the events. These data will be collected from attendees after TTA events (e.g., webinars, recipient meetings, peer learning communities, individualized technical assistance). There are four feedback forms, with each form specific to the type of TTA that participants received. The feedback form for Group Learning Events will be sent out after any group TTA event which is offered to multiple recipients at a time such as webinars, workshops or recipient meetings. The Peer Learning Community feedback form will be sent out periodically to participants who have been actively participating in peer learning communities, such as a Community of Practice. Individual feedback and follow-up forms will be sent out after individual TTA support is received. All Participant Feedback Form data will be used to understand recipients’ perceptions about what is working well and to guide VPTAC in continuously improving future TTA events.

Information gathered via the Participant Feedback Forms will be used only for general training and technical assistance improvement and is not intended for release outside of CDC/NCIPC and funded technical assistance providers. Information gathered will not be used for the purpose of substantially informing influential policy decisions. Without participant feedback, CDC/NCIPC and its funded technical assistance providers will lack timely information to adjust its services to meet customer needs.

DESCRIPTION OF RESPONDENTS: These data will be collected from representatives of approximately 150 recipients across CDC/NCIPC’s programs that are addressing different forms of violence who participate in one or more type of VPTAC technical assistance or training.

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:_____Karen Angel _______

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 [X ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ X ] No

This submission has been reviewed by the NCIPC-CIO’s Information Systems Security Officer, who determined that the Privacy Act does not apply (Att. 1).

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

Category of Respondent	Form Name	No. of Respondents	Participation Time (Hours)	Burden (Hours)
Medical and Health Services Managers	Participant Feedback Form for Group Learning Events (Att. 2)	500	10/60	83.3
Medical and Health Services Managers	Participant Feedback Form for Peer Learning Communities (Att. 3)	100	10/60	16.6
Medical and Health Services Managers	Recipient Feedback Form for Individual TA (Att. 4)	75	15/60	18.75
Medical and Health Services Managers	Recipient Follow Up Form for Individual TA (Att. 5)	50	15/60	12.5
Totals				131

FEDERAL COST: The estimated annual cost to the Federal government is $1,500

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)

Representatives of approximately 150 recipients across CDC/NCIPC’s programs that are addressing different forms of violence who participate in one or more type of VPTAC technical assistance or training. Anyone who participates in the relevant VPTAC activity will be invited to complete these forms. No sampling will be conducted.

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

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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