Public Comments and Response

Attachment 3 – Comments and Response to the 60-day FRN

Association Of State And Territorial Health Officials

2231 Crystal Drive, Suite 450 | Arlington, Virginia 22202

(202) 371-9090 | www.astho.org

December 16, 2010

Carol E. Walker

Centers for Disease Control and Prevention

Acting Reports Clearance Officer

1600 Clifton Road, MS–D74, Atlanta, GA 30333

[email protected]

Re: FR Doc. 2010–26577

Dear Ms. Walker:

The data collection activities outlined in the above referenced notice in the Federal

Register will place an excessive burden on state health agencies. While the Office of

State, Tribal, Local, and Territorial Support at the CDC should have standing clearance to conduct occasional surveys of the state, tribal, local and territorial (STLT) health

agencies it supports, it should not burden them with over 40,000 hours of survey

response each year. In particular, the request to survey state health agencies 50 times

per year is extreme and unnecessary.

ASTHO is the national nonprofit organization representing the public health agencies of

the United States, the U.S. Territories, and the District of Columbia, as well as the

120,000 public health professionals these agencies employ. ASTHO members, the chief

health officials of these jurisdictions, are dedicated to formulating and influencing sound

public health policy and to assuring excellence in state-based public health practice.

ASTHO has a particular interest in this clearance request because the proposed data

collection represents a heavy burden on our members, and because it will interfere with

and possibly duplicate data collection efforts already underway at ASTHO. Many of

these efforts are funded by the CDC.

CDC requests a three-year generic clearance to collect information from STLT health

agencies. CDC estimates that it will conduct up to 50 surveys of state health agencies, 12 surveys of county health agencies, and four surveys of municipal health agencies each year. The surveys may involve large numbers of respondents: all 50 state health

agencies, 1,600 county health agencies, and 20 municipal health agencies. These surveys will be substantial in scope. Though the notice refers to them as “short surveys” CDC estimates that each survey will require one to two hours to complete.

If surveys were conducted at the maximum level, all state health officials would spend

one hour per week responding to CDC data requests, and most local health officials

would spend two hours per month responding to CDC data requests. Completing even a fraction of the surveys for which CDC is seeking generic clearance would constitute a

major burden for STLT health agencies. ASTHO receives considerable feedback about

the burden of the surveys that are already imposed on state health departments.

Adding another lengthy survey almost every week of the year would constitute an

excessive unfunded mandate.

The economic recession has taken a major toll on state health agencies. Collectively,

state health agencies have lost over 15,000 jobs since 2008. They are reducing services and eliminating entire programs due to budget cuts. Asking these agencies to devote up to an hour a week to filling out surveys will further weaken the service they are able to provide to the public.

ASTHO believes that CDC should use existing cooperative agreements with national

associations that represent STLT health agencies to collect data in situations when it is

needed so quickly that normal clearance processes are impractical. CDC already funds

ASTHO to conduct surveys of state health agencies. ASTHO is very careful to minimize

the burden these surveys impose on members. If CDC conducts 50 surveys a year of

state health agencies, ASTHO will be unable to continue the work CDC funds it to do.

State health agencies will be subject to “survey fatigue” and will not respond to any

surveys as consistently as they have to date.

We appreciate the opportunity to comment and ask you to consider the needs of those

we are working to serve.

Sincerely,

Paul E. Jarris, MD, MBA

Executive Director

Association of State and Territorial Health Officials

COMMENTS OF THE NATIONAL ASSOCIATION OF

COUNTY AND CITY HEALTH OFFICIALS

On the Centers for Disease Control and Prevention’s

Proposed Data Collections for State, Tribal, Local, and Territorial Health Agencies

December 16, 2010

The National Association of County and City Health Officials (NACCHO) is pleased to submit

the following comments on the Centers for Disease Control and Prevention’s (CDC’s) Proposed

Data Collections for State, Tribal, Local, and Territorial (STLT) Health Agencies, published in

the Federal Register on October 22, 2010.

NACCHO represents the nation’s 2,800 local health departments. These city, county,

metropolitan, district, and tribal departments work every day to ensure the conditions that

promote health and equity, combat diseases, and improve the quality and length of all lives for

all people in their communities through public health policies and services

While NACCHO agrees that collecting information from STLT health agencies is valuable,

NACCHO is concerned about the proposed level of data collection, which would impose a major

burden on STLT health agencies, and the resulting “survey fatigue” would compromise the

ability of other organizations to collect data from STLT health agencies. NACCHO believes that

CDC should use existing cooperative agreements with national associations that represent STLT health agencies to collect data in situations when data are needed so quickly that normal

clearance processes are impractical.

A. The number and length of surveys for which CDC seeks clearance poses a major

burden to STLT health agencies. CDC requests a three-year generic clearance to collect information related to myriad issues that affect STLT health agencies. CDC estimates that it will conduct up to 50 surveys of state health agencies, 12 surveys of county health agencies, and four surveys of municipal health agencies each year. The surveys may involve large numbers of respondents: all 50 state health agencies, 1,600 county health agencies, and 20 municipal health agencies. These surveys will be substantial in scope. Though the notice refers to them as “short surveys” CDC estimates that each survey will require one to two hours to complete.

If surveys were conducted at the maximum level, all state health officials would spend one hour

per week responding to CDC data requests, and most local health officials would spend two

hours per month responding to CDC data requests. Completing even a fraction of the surveys for which CDC is seeking generic clearance would constitute a major burden for STLT health

agencies. NACCHO typically conducts only one survey of the scope and size of the surveys for

which CDC is seeking generic clearance: the National Profile of Local Health Departments

(Profile), which is administered once every two to three years. Despite the relative infrequency

of the Profile survey and the high value local health departments place on the findings of the

Profile, NACCHO receives considerable feedback about the burden that this survey imposes on

local health agencies. NACCHO believes local health officials would find completing a lengthy

survey each month extremely burdensome.

Many local health agencies employ very small numbers of staff. Thirty-eight percent of local

health agencies employ less than 10 full-time equivalent staff. Responding to lengthy surveys is

an especially great burden for these small agencies. Furthermore, local health agencies of all

sizes have lost staff positions over the past two years. NACCHO estimates that local health

agencies lost a cumulative 23,000 jobs between January 2008 and December 2009,

approximately 15 percent of the total local health agency workforce.

B. Providing “generic clearance” will remove an important incentive to reduce data

collection burden. An important goal of the paperwork reduction act is to minimize the burden of government data collection. NACCHO strongly supports this goal and considers data collection a burden in its own efforts, as well. The intended use of the information should guide both the content of a survey (and therefore its length) and the size of the sample to which the survey is administered. Many surveys do not require such precise estimates that a sample of 1,600 county health agencies would be required. NACCHO has found that a sample of approximately 500 to 600 local health agencies is sufficient for most purposes and that considerably smaller sample sizes can provide useful information for some purposes, such as situational awareness.

Working with external researchers (at both CDC and academic institutions) has taught NACCHO that researchers typically want to use the largest sample size feasible and seek detailed information on their topic of interest. This is not surprising, because a researcher’s main concern is the quality of his or her own research, not the cumulative burden on the respondents.

NACCHO spends considerable time working with these researchers to reduce the length of the

survey instruments and to determine how large a sample is actually required to support the goals of the research. Giving automatic clearance for a lengthy survey and a large sample size removes an important incentive for researchers to consider the burden of their data collection efforts on the STLT agencies.

C. The resulting “survey fatigue” will compromise the ability of other organizations to

collect information from STLT health agencies. CDC is not the only organization that seeks to collect data from STLT health agencies. NACCHO receives many comments from local health agencies about the volume of surveys that they receive. Local health agencies receive surveys from many different kinds of organizations, including local organizations, state health agencies, federal agencies, academic researchers (including schools of public health), and professional organizations that represent them at the state and national levels. The purposes of these surveys include needs assessments, program monitoring, surveillance, evaluation, advocacy, and building the evidence base for public health. Most of the surveys are beneficial in some way, but all add to the data collection burden on local health agencies.

When STLT staff members (or any targets of surveys) receive a large number of surveys to

complete, they typically experience “survey fatigue” and will stop responding to surveys or

respond only to those they deem most important. This means that many surveys will achieve low response rates, and the findings of the surveys will not be reliable. Sending up to 12 lengthy

surveys per year to county health agencies and 50 surveys per year to state health agencies would certainly contribute to survey fatigue.

NACCHO is particularly concerned about the impact of the proposed surveys on its Profile

study. The Profile survey is unique in both its design and the wide availability of the data from

the survey. The Profile is a longitudinal survey administered to every local health agency in the

United States; the survey collects data on infrastructure (governance, funding, workforce) and

activities. It is essentially a surveillance system for the status of U.S. local health agencies.

NACCHO provides data from the Profile survey to researchers in other organizations, including

government agencies and universities. NACCHO has provided Profile data to external

researchers for over 75 studies since 2006. NACCHO has consistently achieved response rates of 80 percent or more on the Profile survey, but increasing efforts in terms of follow-up have been required to continue to achieve high response rates. A poor response to the Profile survey not only impacts the usefulness of the study as a surveillance system but also affects the validity of all of the studies that rely on Profile data as a major component of their research.

D. CDC can use other mechanisms to collect information from STLT health agencies

in a rapid manner and does not need generic clearance for such a large number of

surveys. NACCHO believes that STLT agencies are critical partners for many of CDC’s programs and that additional information about STLT health agencies can improve CDC’s decision-making and program planning. CDC does not, however, need the requested generic clearance to obtain useful information. For data collection activities that are not particularly time-critical, CDC can use the normal processes for obtaining clearance for data collection activities. For data collection activities that are time-critical, CDC can work through its existing cooperative agreements with national associations to collect the needed data in a collaborative manner. Both NACCHO and the Association of State and Territorial Health Officials (ASTHO) have the organizational capacity to collect data from their respective agency members. NACCHO has conducted many data collection activities, including its Profile studies, in collaboration with CDC. Recent examples include a series of quick response surveys to a network of approximately 150 LHDs to assess (in real time) LHDs activities in response to the H1N1 virus and a more lengthy post-response survey on the same topic administered to a statistical sample of LHDs. Collaborating with national partners that represent the survey respondents is an excellent way to ensure that the surveys minimize burden and maximize benefit to the survey respondents.

Contact: Carolyn J. Leep, Director, Research and Evaluation

(202) 507 – 4241

[email protected]

Response to comments on the Centers for Disease Control and Prevention’s (CDC’s) Proposed Data Collections for State, Tribal, Local, and Territorial (STLT) Health Agencies, FR Doc. 2010–26577, published in the Federal Register on October 22, 2010

To whom it may concern,

Comments provided by the Association of State and Territorial Health Officials (ASTHO) and the National Association of City and County Health Officials (NACCHO) dated December 16, 2010 have been carefully reviewed.  We agree that state, local, tribal, and territorial health agencies represented by ASTHO and NACCHO provide important information to the broad interests of national public health through their respective profile surveys and other special surveys.

CDC’s generic clearance request is intended to answer questions of immediate public health importance and proposed surveys will, in every ICR, go first to data already collected by CDC or its partners.  Furthermore, CDC’s proposed generic clearance is intended to reach government employees in many settings such as police, fire, higher education, social work, public health, government hospitals and other settings not covered by ASTHO and NACCHO efforts.  It is important to note that CDC efforts under this generic clearance will not be duplicative of ASTHO and NACCHO information collections. 

We too are concerned about potential burden to respondents and the burden hours listed in the generic clearance request represents the upper limit possible in a year, not survey-hour goals we intend to achieve annually. Asking outside agencies, such as ASTHO and NACCHO, to collect data for CDC without a generic clearance in place does not negate OMB/ PRA regulations.  Having the generic clearance in place would, however, enable such a working relationship were in the best interests of CDC.

We appreciate the time both ASTHO and NACCHO took in providing their comments and look forward to working with them in our ICR efforts wherever possible.

Timothy W. Van Wave, DrPH, MPH

Branch Chief (acting) Research and Outcomes Branch

Health Scientist, Research & Outcomes Branch

Office for State, Tribal, Local, and Territorial Support

Centers for Disease Control & Prevention

1825 Century Center  MS-70

Atlanta, Georgia  30345

Office -          404-498-0336

Blackberry - 404-697-5406

Fax -               404-498-6882