GenIC Request

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: Advancing Data for Public Health Action Survey

PURPOSE:

The purpose of this survey is to inform and improve CDC’s efforts moving towards its future vision of advancing public health data.

DESCRIPTION OF RESPONDENTS:

Respondents are state, tribal, local, and territorial (STLT) public health agency staff or public health organization partner staff who work in roles that are impacted by the decisions and priorities that CDC makes. This can include: health department directors, data standards and legal strategists, IT staff, informatics staff, epidemiologists, administrators, nurses, among other types of staff working in public health settings. This includes the public health professionals who have opted-in to CDC’s Engagement Panel as well as members in Data Modernization Initiative (DMI) partner organizations we are working with. We are targeting 500 respondents over the course of 12 months. We’ll be generating a unique URL for each audience we target.

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:_Suzanne Soroczak_____________________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [N] 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

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	No. of Respondents	Participation Time	Burden
State, local, or tribal governments	500	15/60	125 Hours
Total			125 hours

FEDERAL COST: The estimated annual cost to the Federal government is _$2360___

Staff	Estimated Hours	Hourly Rate	Total Cost
1 FTE Data Scientist from OPHDST Technology Strategy Office will be programming the survey in Qualtrics, distributing it to a list of participants, and completing the data analysis and reporting the results.	4	90	$360
License for Qualtrics XM software			$2000
Total			$2360

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)

1. Customer list that defines the universe of potential respondents: As part of the CDC Data Modernization Initiative (DMI), we have asked state, tribal, local, and territorial (STLT) health department staff, as well as a variety of medical and environmental health professionals to opt-in to CDC Engagement Panel. In the Engagement Panel, they listed their organization, health department (if applicable), type of organization (e.g., local, state, territory, partner), and area(s) of expertise. They have also opted-in to receive this type of surveys periodically throughout the year.

2. Sampling plan: We plan to invite all Engagement Panel members to participate in this survey. We will also be inviting public health partner members to take the survey after in-person conferences and workshops (e.g. NACCHO 360, CSTE 2025, or OPHDST/STLT Data Connection).

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)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[X] Other, Qualtrics XM survey

2. Will interviewers or facilitators be used? [] Yes [ X ] No

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

See Appendix A for above

5