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.

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

TITLE OF INFORMATION COLLECTION: Three-Month Survey: Module WB4518, Talking about Naloxone

PURPOSE:

Since the 2016 release of the CDC Guideline for Prescribing Opioids for Chronic Pain, new evidence has emerged on the risks and benefits of prescription opioids for acute, subacute, and chronic pain. As a result, CDC published the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2022 CDC Clinical Practice Guideline). The updated 2022 CDC Clinical Practice Guideline prompted the development of new training modules, while also ensuring that existing drug overdose clinician training was retained and updated to align with the latest recommendations. CDC’s online training series aims to help healthcare professionals apply CDC’s recommendations in clinical settings through patient scenarios, videos, knowledge checks, tips, and resources.

After learners take an online training module, they must complete a course evaluation survey to earn continuing education. This survey is administered by CDC’s Training and Continuing Education Online (TCEO). In order to better assess actual behavior change and the utility of the training in clinical practice, a longer period is needed between training and follow-up assessment. To accomplish this, we will be conducting a three-month follow-up survey (Att. 3 and 4-Screenshots). The survey will target the Talking about Naloxone training module (WB4518).

The survey will be conducted among learners who have completed the Talking about Naloxone training module (WB4518). Results will not be generalizable outside of this population. Incentives will not be provided. Information will only be used internally to CDC. Without these types of feedback, the Agency will not be able to improve current and future resources to meet recommendations in clinical settings.

DESCRIPTION OF RESPONDENTS:

Participation in the survey will be voluntary. Users will provide feedback through an online survey hosted by Survey Monkey. Participants will include learners who have completed the Talking about Naloxone training module.

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 [ ] No

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

This submission has been reviewed by the NCIPC’s Information Systems Security Officer, who has determined that the Privacy Act does not apply for this information collection request (Attachment 1). Personal Private Information is not collected. All procedures have been developed, in accordance with federal, state, and local guidelines, to ensure that the rights and privacy of respondents will be protected and maintained.

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	Burden (hours)
Learners who have completed the Talking about Naloxone training module	Three-month follow up survey (Att. 3)	100	15/60	25
Totals		100	15/60	25

FEDERAL COST: The estimated annual cost to the Federal government is $27,000

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)

The participant list includes learners who have taken the Talking about Naloxone CDC training module (WB4518) three months after taking the training.

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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