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.

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

TITLE OF INFORMATION COLLECTION: Translating Evidence to Practice Implementation Tools for Preventing Overdose

PURPOSE: The purpose of this data collection is to understand perspectives of public health partners implementing overdose prevention activities in the field and their needs in regard to implementation tools that help support these activities. Understanding their feedback on existing materials and gaps in existing materials will be essential for developing new materials that are actionable and implementable for partners. The proposed project intends to support the development of actionable tools and implementation guidance materials on solutions to current issues and challenges in overdose prevention with topics including but not limited to; community responses to changing drug supply landscape and patterns of use, strategies for overdose prevention for individuals who use drugs alone, grief support and wellness for patient navigators, a qualitative understanding of health departments’ experiences implementing linkage to care (L2C) and L2C surveillance, and strategies that support retention and reengagement in care. This project is a cooperative agreement with the National Council of Mental Wellbeing, who will help lead the data collection, data synthesis, and product development. This data collection will be administered by survey. The purpose of the survey and follow-up key informant interviews is two-fold: 1) to determine what general overdose prevention/substance use resources are helpful for the field and 2) to assess the utility of tools the National Council and CDC have previously developed and disseminated. This results from this data collection will inform the development of implementation tools such as informing type of tool (i.e. briefings, templates, webinars, worksheets, etc.), length of tools, strategies for dissemination, and audience of the tools.

DESCRIPTION OF RESPONDENTS: Respondents will be individuals who utilize overdose intervention materials and tools, including OD2A: LOCAL and State recipients (90) and NCMW listserv participants (expected 180 respondents).

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: Miranda Gali, Natanya Robinowitz, Rebecca Glover-Kudon

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

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
OD2A Recipients & NCMW Harm Reduction Listserv Respondents	Tools for Overdose Prevention Survey Att 1	270	40/60	180 hours
OD2A Recipients & NCMW Harm Reduction Listserv Respondents	Recruitment email Att 2	270	2/60	9 hours
Totals				189 hours

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)

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 list of respondents will include OD2A:LOCAL and OD2A State recipients as well as NCMW’s listserv. These lists are already cultivated.

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, Explain – Email based communication

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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