0920-1050 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:

Survey for Soliciting Feedback on National Healthcare Safety Network Education and Training Assessment

PURPOSE:

The purpose of the National Healthcare Safety Network (NHSN) Training Needs Assessment survey is to identify and meet the training needs of those who use the NHSN Patient Safety Component and to gauge users’ current knowledge and use of available training and education resources. The results of the 15-minute survey will help the NHSN team determine whether the available training resources are meeting the needs of NHSN users and inform development of future training and education materials and activities.

The needs assessment survey results will provide information on NHSN users’ current use of the existing training and education resources and their attitudes and perceptions of the accessibility and utility of the training and education resources. Additionally, the survey will help identify the modules or topics where additional training resources are needed. All questions are required, any feedback text boxes can be optional.

DESCRIPTION OF RESPONDENTS:

NHSN End Users from Different Professional Roles:

Infection Preventionist

Epidemiologist

Registered Nurse

Microbiologist

Quality Improvement Specialist

Medical Technologist

Administrator

Data Analyst

Physician

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: Toni Brown Ector

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

Category of Respondent	No. of Respondents	Participation Time	Burden
NHSN Healthcare Facility End Users	43,537	15 min	10884
Totals	43,537	15/60	10884

FEDERAL COST: The estimated annual cost to the Federal government is $17,270.

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)

NHSN email distribution list

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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