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? Yes

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? No

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:

National Syndromic Surveillance (NSSP) Community of Practice (CoP) Survey

PURPOSE:

CDC is partnering with the Council of State and Territorial Epidemiologists (CSTE), to improve the use of syndromic surveillance throughout the nation. CDC funded CSTE through a cooperative agreement, “Strengthening Public Health Systems and Services through National Partnerships to Improve and Protect the Nation’s Health”. The National Syndromic Surveillance Program (NSSP) Community of Practice (CoP) comprises over 1,400 syndromic surveillance practitioners and data experts across the country working at the State, Tribal, Local, and Territorial (STLT) and federal levels. The goal of the survey would be to enhance member experience and identify topics for knowledge sharing events and/or trainings. Information gathered will be internal to CDC to assess needs and to improve CDC services to public health agencies.

DESCRIPTION OF RESPONDENTS:

Potential respondents will include the approximate 1,400 members of the NSSP CoP comprised of public health workers at the state, tribal, local, and territorial public health and federal levels.

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:__Sylvia Murphy DVM MHS ________________________________________

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

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden (In hours)
State, local, or tribal governments (baseline survey)	1400	15 minutes	350

FEDERAL COST:  The estimated annual cost to the Federal government is $1,064.22. This is based on pay for one CSTE staff member and the time required for designing the survey, reaching out to potential respondents, and conducting a descriptive analysis of results.

Estimated Annualized Cost to the Federal Government

Staff (FTE)	Estimated Hours	Hourly Rate	Total Cost
CSTE Staff- Design, outreach and descriptive analysis	25	$42.57 /hour	$1064.22
Survey software- no cost, will use existing account of CSTE with survey system	N/A	$0	$0
Total			$1064.22

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 CDC funded organization (CSTE) assumed a formal role of governing body of the NSSP CoP in 2020. CSTE will make the survey available to all members of the NSSP CoP. The brief survey has 25 questions (a combination of Likert scale, multiple choice, and open-ended questions), the method will request responses from all NSSP CoP members (approximately 1400 persons) who represent public health workers across the country at the State, Tribal, Local, and Territorial (STLT) health agencies and at the federal level. The brief survey will be distributed to all individuals on the NSSP CoP distribution lists for voluntary participation. The number of respondents in the Burden Hours table reflects respondents if there is full participation by all members of the NSSP CoP.

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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