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

Forms and Documents

Document Name	Status
2014 EIS Conference Customer Feedback Survey Form	New
Pilot Messaging Campaign Follow-up Survey Form	New
DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators Form	New
Disability and Health Data System User Feedback Survey Form and Instruction	New
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
Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE) Form	New
English Language Folic Acid Educational Materials: Message Testing and Materials Development Form	New
Form 1 Risk of Alcohol Use During Pregnancy: Message Testing and Materials Development Form and Instruction	New
Customer Satisfaction Survey of Preconception Health Adcepts Form	New
SS Part B_FAST TRACK.docx Supporting Statement B	2011-12-20
SS Part A .docx Supporting Statement A	2011-12-20

IC Document Collections

IC ID	Document Title	Status
211095	2014 EIS Conference Customer Feedback Survey Form	New
210966	GenIC Testing Act Early Messages for "Learn the Signs. Act Early Other-WORD	New
208813	Pilot Messaging Campaign Follow-up Survey Form	New
207599	DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators Form	New
206847	Disability and Health Data System User Feedback Survey Form and Instruction	New
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
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
202174	English Language Folic Acid Educational Materials: Message Testing and Materials Development Form	New
201748	Risk of Alcohol Use During Pregnancy: Message Testing and Materials Development Form and Instruction	New
201393	Customer Satisfaction Survey of Preconception Health Adcepts Form	New

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
	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.

	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

IC Title	Form No.	Form Name
Risk of Alcohol Use During Pregnancy: Message Testing and Materials Development	1	Recruitment Screener for Focus Groups
2014 EIS Conference Customer Feedback Survey	none	Survey Screenshots
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
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
Materials Testing to Develop and Enhance Recruitment Material for SEED - phase 2
GenIC Testing Act Early Messages for "Learn the Signs. Act Early
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
Customer Satisfaction Survey of Preconception Health Adcepts	none, none	Screener ,   Customer Service Survey
English Language Folic Acid Educational Materials: Message Testing and Materials Development	none, none	Consent ,   Screener
Disability and Health Data System User Feedback Survey	none, None	DHDS User Feedback Survey ,   DHDS User Feedback Survey
Pilot Messaging Campaign Follow-up Survey	none	Customer Satisfaction Survey-Pilot Messaging Campaign Follow-up Survey
ADDM Network: Communication Materials Testing and Development

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ICR Summary 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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