Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Survey Screenshots	Form	New	Available
Customer Satisfaction Survey-Pilot Messaging Campaign Follow-up Survey	Form	New	Available
Disability and Health Branch Site Visit	Form	New	Available
Disability and Health Interventions	Form	New	Available
Post Evaluation Webinar	Form	New	Available
Resource Center Eval Think Tank	Form	New	Available
State Evaluation Think Tank Group Feedback	Form	New	Available
State Evaluation Think Tank	Form	New	Available
Resource Center Evaluation	Form	New	Available
Workplan Feedback Survey	Form	New	Available
Monthly Conference Call Evaluation	Form	New	Repair queued
Interim Progress Report	Form	New	Available
Annual Grantee Meeting Survey	Form	New	Available
DHDS User Feedback Survey	Form and Instruction	New	Available
DHDS User Feedback Survey	Form and Instruction	New	Available
Amazing Me-It's Busy 3! Book Survey	Form and Instruction	New	Available
Informed Consent Atlanta-evening	Form	New	Available
Focus Group Discussion Guide	Form	New	Available
Informed Consent Baltimore	Form	New	Available
Informed Consent Atlanta	Form	New	Available
Rescreener	Form	New	Available
Screener Baltimore Male 40-64	Form	New	Available
Screener Baltimore Female 65-80	Form	New	Available
Screener Baltimore Male 18-39	Form	New	Available
Screener Baltimore Female 18-39	Form	New	Available
Screener Atlanta Female 40-64	Form	New	Available
Screener Atlanta Male 65-80	Form	New	Available
Screener Atlanta Female 18-39	Form	New	Available
Screener Atlanta Male 40-64	Form	New	Available
Screener	Form	New	Available
Consent	Form	New	Available
Form 1 Recruitment Screener for Focus Groups	Form and Instruction	New	Available
Customer Service Survey	Form	New	Available
Screener	Form	New	Available
SS Part B_FAST TRACK.docx	Supporting Statement B	Uploaded 2011-12-20	Available
SS Part A .docx	Supporting Statement A	Uploaded 2011-12-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
211095	2014 EIS Conference Customer Feedback Survey	Form	New	Survey Screenshots
210966	GenIC Testing Act Early Messages for "Learn the Signs. Act Early	Other-WORD	New
208813	Pilot Messaging Campaign Follow-up Survey	Form	New	Customer Satisfaction Survey-Pilot Messaging Campaign Follow-up Survey
207599	DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators	Form	New	Disability and Health Branch Site Visit
207599	DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators	Form	New	Disability and Health Interventions
207599	DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators	Form	New	Post Evaluation Webinar
207599	DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators	Form	New	Resource Center Eval Think Tank
207599	DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators	Form	New	State Evaluation Think Tank Group Feedback
207599	DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators	Form	New	State Evaluation Think Tank
207599	DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators	Form	New	Resource Center Evaluation
207599	DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators	Form	New	Workplan Feedback Survey
207599	DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators	Form	New	Monthly Conference Call Evaluation
207599	DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators	Form	New	Interim Progress Report
207599	DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators	Form	New	Annual Grantee Meeting Survey
206847	Disability and Health Data System User Feedback Survey	Form and Instruction	New	DHDS User Feedback Survey
206847	Disability and Health Data System User Feedback Survey	Form and Instruction	New	DHDS User Feedback Survey
204835	Exploration of Distribution and Reach of Educational Children's Book Amazing Me- It's Busy Being 3! In Pediatric Office Settings	Form and Instruction	New	Amazing Me-It's Busy 3! Book Survey
202929	Materials Testing to Develop and Enhance Recruitment Material for SEED - phase 2	Instruction	New
202838	ADDM Network: Communication Materials Testing and Development	Other-Moderator's Guide	New
202588	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Form	New	Informed Consent Atlanta-evening
202588	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Form	New	Focus Group Discussion Guide
202588	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Form	New	Informed Consent Baltimore
202588	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Form	New	Informed Consent Atlanta
202588	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Form	New	Rescreener
202588	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Form	New	Screener Baltimore Male 40-64
202588	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Form	New	Screener Baltimore Female 65-80
202588	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Form	New	Screener Baltimore Male 18-39
202588	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Form	New	Screener Baltimore Female 18-39
202588	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Form	New	Screener Atlanta Female 40-64
202588	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Form	New	Screener Atlanta Male 65-80
202588	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Form	New	Screener Atlanta Female 18-39
202588	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Form	New	Screener Atlanta Male 40-64
202174	English Language Folic Acid Educational Materials: Message Testing and Materials Development	Instruction	New
202174	English Language Folic Acid Educational Materials: Message Testing and Materials Development	Form	New	Screener
202174	English Language Folic Acid Educational Materials: Message Testing and Materials Development	Form	New	Consent
201748	Risk of Alcohol Use During Pregnancy: Message Testing and Materials Development	Other-Focus Group Guide	New
201748	Risk of Alcohol Use During Pregnancy: Message Testing and Materials Development	Form and Instruction	New	Recruitment Screener for Focus Groups
201393	Customer Satisfaction Survey of Preconception Health Adcepts	Form	New	Customer Service Survey
201393	Customer Satisfaction Survey of Preconception Health Adcepts	Form	New	Screener

ICR Details

OMB Control No: 0920-0919	ICR Reference No: 201112-0920-014
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/30/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/20/2011
Terms of Clearance: OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2015	36 Months From Approved
Responses	28,000	0	0
Time Burden (Hours)	18,667	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information is necessary to enable National Center on Birth Defects and Developmental Disabilities to garner customer and stakeholder feedback in an efficient and timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the Agency's programs.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 80542	12/22/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 77835	12/14/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 12

table that charts list of burden

IC Title	Form No.	Form Name
2014 EIS Conference Customer Feedback Survey	none	Survey Screenshots
ADDM Network: Communication Materials Testing and Development
Customer Satisfaction Survey of Preconception Health Adcepts	none, none	Screener ,   Customer Service Survey
DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators	none, none, none, none, none, none, none, none, none, none, none	Annual Grantee Meeting Survey ,   Interim Progress Report ,   Monthly Conference Call Evaluation ,   Workplan Feedback Survey ,   Resource Center Evaluation ,   State Evaluation Think Tank ,   State Evaluation Think Tank Group Feedback ,   Resource Center Eval Think Tank ,   Post Evaluation Webinar ,   Disability and Health Interventions ,   Disability and Health Branch Site Visit
Disability and Health Data System User Feedback Survey	none, None	DHDS User Feedback Survey ,   DHDS User Feedback Survey
English Language Folic Acid Educational Materials: Message Testing and Materials Development	none, none	Consent ,   Screener
Exploration of Distribution and Reach of Educational Children's Book Amazing Me- It's Busy Being 3! In Pediatric Office Settings	None	Amazing Me-It's Busy 3! Book Survey
GenIC Testing Act Early Messages for "Learn the Signs. Act Early
Materials Testing to Develop and Enhance Recruitment Material for SEED - phase 2
Pilot Messaging Campaign Follow-up Survey	none	Customer Satisfaction Survey-Pilot Messaging Campaign Follow-up Survey
Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	none, none, none, none, none, none, none, none, none, none, none, none, none	Screener Atlanta Male 40-64 ,   Screener Atlanta Female 18-39 ,   Screener Atlanta Male 65-80 ,   Screener Atlanta Female 40-64 ,   Screener Baltimore Female 18-39 ,   Screener Baltimore Male 18-39 ,   Screener Baltimore Female 65-80 ,   Screener Baltimore Male 40-64 ,   Rescreener ,   Informed Consent Atlanta ,   Informed Consent Baltimore ,   Focus Group Discussion Guide ,   Informed Consent Atlanta-evening
Risk of Alcohol Use During Pregnancy: Message Testing and Materials Development	1	Recruitment Screener for Focus Groups

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	28,000	0	0	28,000	0	0
Annual Time Burden (Hours)	18,667	0	0	18,667	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new generic ICR submitted under the fast track mechanism.

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Annual Cost to Federal Government: $365,500

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/20/2011

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