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: Comprehensive Suicide Prevention (CSP) Evaluation Learning Network Questionnaire

PURPOSE:

• Determine the level of customer satisfaction among Comprehensive Suicide Prevention Program recipients regarding participation in webinars, workgroups, and group technical assistance activities specifically within the CSP Evaluation Learning Network with CDC support staff.

• Use of Respondent Information

  • Information and feedback gathered from the questionnaire will be used to enhance the CSP Evaluation Learning Network, ensuring topics, sessions, and group technical assistance activities are relevant and valuable to CSP recipients.

  • The insights aim to inform continuous quality improvement for the CSP Evaluation Learning Network practices, strengthening collaboration among CSP recipient evaluators to one another, and guiding the development of future technical assistance within the network.

DESCRIPTION OF RESPONDENTS:

Respondents to this information collection are staff at state and local health departments, universities, and nonprofits that are funded via the Comprehensive Suicide Prevention program (CSP). CSP funds state and local health departments to implement and evaluate a comprehensive approach to suicide prevention in their jurisdictions. CSP aims to reduce suicide mortality and morbidity among populations disproportionately affected by suicide.

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 Mary Halstead_______________________________________

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

No incentive will be provided.

BURDEN HOURS

The target respondents will be Comprehensive Suicide Prevention Program recipients participating in webinars, workgroups, and other group technical assistance with CDC support staff. The survey will be administered to 80 participants per event at 4 events per year via Redcap, with a total of 320 respondents. Each feedback response takes an average of 10 minutes to complete (Attachment 1).

Category of Respondent	Form Name	No. of Respondents	Participation Time	Burden
State health department staff, local health departments, nonprofits, universities funded by Comprehensive Suicide Prevention (CSP)	Comprehensive Suicide Prevention (CSP) Evaluation Learning Network Questionnaire (Att 1)	320	10/60	53
Totals				53

FEDERAL COST: The estimated annual cost to the Federal government is $3,309. GS-9- 2 weeks and GS-13 1week to develop Routine Customer Feedback form, data collection tools, and complete and process OMB PRA application.

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

This Routine Customer Feedback form will only be shared with program staff at organizations funded by the Comprehensive Suicide Prevention Program (CSP) who participate in group technical assistance events such as webinars and workgroups. The email listserv is maintained by the lead Project Officer for the CSP cooperative agreement. No sampling will be conducted.

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

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