GenIC Request Template - 0920-1050

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:

2024 Infection Prevention and Control Webinar Training Series - Session Feedback Form

 

PURPOSE:

The Centers for Disease Control and Prevention’s (CDC) Health Systems Strengthening Resilience & Training (HSSRT) Branch in partnership with Indian Health Service (IHS) is hosting a 5-part webinar training series on CDC guidelines for infection prevention and control to healthcare personnel. This bundle series will cover essential topics such as risk recognition and germ spread, hand hygiene, personal protective equipment (PPE), bloodborne pathogens, environmental cleaning and disinfection, and an overview of IHS Chapter 3-33 Infection Prevention and Control Policy. By the end of these training sessions, participants will be able to explain why it’s important to follow the CDC guidelines for preventing the spread of infection within their healthcare facility.

Participants will also have the opportunity to complete a survey (Attachment B) documenting their training experience at the end of the entire 5-part series or individual sessions attended. Survey data will be collected using Qualtrics which is a web-based survey tool used to build and disseminate surveys. Qualtrics is an approved CDC software. The estimated burden of each survey is less than 12 minutes and is completely voluntary.

We anticipate survey results will provide keen insights into target audience demographics (e.g., professional role/setting, work location, years of experience), capacity building, practical use and value of content. We’ve included placeholders where we will ask about specific learning objectives. Attachment D has a list of the possible learning objectives. Results will not be published but will inform the design, implementation, and marketing of future IHS trainings and events.

DESCRIPTION OF RESPONDENTS:

Respondents of these instruments are attendees of the 2024 Infection Prevention and Control Webinar Training Series hosted by the Indian Health Service (IHS). They received an open invitation to attend based on their occupation as healthcare professionals, including clinical (patient care) and non-clinical staff. 

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: Jana Shamburger

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
Healthcare Professionals	1,500	12 minutes	300 hours
Totals

FEDERAL COST: The estimated annual cost to the Federal government is $5544.84_

Information Collection	Activity	Average Hours (annually)	Average Hourly Rate	Total Cost
Evaluation	Data pulled from Qualtrics by HSSRTB staff	1	$113.16	$113.16
	Data cleaning, quality check, and analysis by HSSRTB staff	24	$113.16	$2715.84
	Creation of report	24	$113.16	$2715.84
Total	All activities combined…	49	$113.16	$5544.84

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

For those participants who successfully register and attend the training sessions, we will distribute a follow up email soliciting a survey response using the contact information provided. Session facilitators will also encourage survey participation and the end of each session by presenting a slide with a QR code directly linking them to the Qualtrics survey.

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

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.

Survey instrument attached to this request:

1. 2024 Infection Prevention and Control Webinar Training Series - Session Feedback Survey

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a concise description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a concise description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument. The ‘Other’ category should be used only in the contexts in which the provided categories cannot reasonably apply.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions.

Gifts or Payments: As a general matter, incentives are not appropriate for customer service collections; however, incentives may be appropriate for focus groups or in-depth usability studies, especially when participants must travel to a site to participate. In the latter circumstance, the incentive should include travel costs. Customary incentives for focus groups in the Federal government are $40 for a one-hour interview and $75 for a 90-minute focus group. If you answer yes to the question, please describe the incentive and provide a justification for amounts other than those cited above; justifications should be limited to Federal studies of a similar design and subpopulation.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households; (2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

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

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