Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIOSH 2)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Survey to Improve Worker Notification Efforts - #3	Form	New	Repair queued
Worker Notification Survey	Form	New	Available
NIOSH Fatigue Prevention Training Module Survey	Form and Instruction	New	Repair queued
Form 0920-0953 WTC screen shots	Form and Instruction	New	Available
Form 0920-0953 WTC Customer Satisfaction Survey	Form and Instruction	New	Available
Long Island Patient Satisfaction Survey	Form	New	Available
Medical Practice Survey	Form and Instruction	New	Available
Form 0920-0953 Patient Satisfaction Survey-Rutgers 12.10.13	Form and Instruction	New	Available
Members in the WTCHP General Responders Consortium Polish Version	Form and Instruction	New	Available
Members in the WTCHP General Responders Consortium--Spanish Version	Form and Instruction	New	Available
World Trade Center Health Program Member Questionnaire	Form and Instruction	New	Available
Manual of Analytical Methods Survey	Form	New	Available
Generic_Clearance_Submission_Template[1].doc	Supplementary Document	Uploaded 2012-11-01	Available
NIOSH Part SS-B.docx	Supporting Statement B	Uploaded 2012-11-01	Available
NIOSH Part SS-A.docx	Supporting Statement A	Uploaded 2012-11-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
216450	Survey to Improve Worker Notification Efforts #3	Form	New	Survey to Improve Worker Notification Efforts - #3
216300	Survey #2	Other-WORD	New
216239	Survey to Improve Worker Notification Efforts	Form	New	Worker Notification Survey
215418	Fatigue Management Training Module for Emergency Responders Evaluation	Other-WORD	New
215154	Fatigue Management Training Module for Emergency Reponders Evaluation	Other-PDF	New
214089	Fatigue Prevention Training Module Customer Satisfaction and Feedback Survey	Form and Instruction	New	NIOSH Fatigue Prevention Training Module Survey
212365	The World Trade Center Health Program Customer Satisfaction Survey	Form and Instruction	New	WTC screen shots
212365	The World Trade Center Health Program Customer Satisfaction Survey	Form and Instruction	New	WTC Customer Satisfaction Survey
210087	Logistics Health Incorporated (LHI)	Other-WORD	New
209938	The Nationwide Provider Network Customer Satisfaction Survey	Other-WORD	New
209780	Long Island WTC Health Program Survey	Form	New	Long Island Patient Satisfaction Survey
209700	North Shore LIJ Customer Satisfaction Survey	Form and Instruction	New	Medical Practice Survey
209666	The World Trade Center Health Program for Responders at Rutgers University Customer Satisfaction Survey	Form and Instruction	New	Patient Satisfaction Survey-Rutgers 12.10.13
208833	World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey (Spanish and Polish versions)	Form and Instruction	New	Members in the WTCHP General Responders Consortium Polish Version
208833	World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey (Spanish and Polish versions)	Form and Instruction	New	Members in the WTCHP General Responders Consortium--Spanish Version
207187	World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey	Form and Instruction	New	World Trade Center Health Program Member Questionnaire
207187	World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey	Instruction	New
205531	Manual of Analytical Methods Customer Satisfaction Survey	Form	New	Manual of Analytical Methods Survey

ICR Details

OMB Control No: 0920-0953	ICR Reference No: 201211-0920-003
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 (NIOSH 2)
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: 12/21/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/01/2012
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	12/31/2015	36 Months From Approved
Responses	334,500	0	0
Time Burden (Hours)	86,250	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information is necessary to enable the Agency to garner customer and stakeholder feedback in an efficient, 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. This feedback will provide insights into customer or stakeholder perceptions, experiences and expectations, provide an early warning of issues with service, or focus attention on areas where communication, training or changes in operations might improve delivery of products or services. These collections will allow for ongoing, collaborative and actionable communications between the Agency and its customers and stakeholders. It will also allow feedback to contribute directly to the improvement of program management.

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Authorizing Statute(s): PL: Pub.L. 91 - 596 20 Name of Law: Occupational Safety and Health Act of 1970
  

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:
	77 FR 61409	10/09/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Fatigue Management Training Module for Emergency Reponders Evaluation
Fatigue Management Training Module for Emergency Responders Evaluation
Fatigue Prevention Training Module Customer Satisfaction and Feedback Survey	None	NIOSH Fatigue Prevention Training Module Survey
Logistics Health Incorporated (LHI)
Long Island WTC Health Program Survey	none	Long Island Patient Satisfaction Survey
Manual of Analytical Methods Customer Satisfaction Survey	none	Manual of Analytical Methods Survey
North Shore LIJ Customer Satisfaction Survey	None	Medical Practice Survey
Survey #2
Survey to Improve Worker Notification Efforts	none	Worker Notification Survey
Survey to Improve Worker Notification Efforts #3	none	Survey to Improve Worker Notification Efforts - #3
The Nationwide Provider Network Customer Satisfaction Survey
The World Trade Center Health Program Customer Satisfaction Survey	0920-0953, 0920-0953	WTC Customer Satisfaction Survey ,   WTC screen shots
The World Trade Center Health Program for Responders at Rutgers University Customer Satisfaction Survey	0920-0953	Patient Satisfaction Survey-Rutgers 12.10.13
World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey	None	World Trade Center Health Program Member Questionnaire
World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey (Spanish and Polish versions)	None, None	Members in the WTCHP General Responders Consortium--Spanish Version ,   Members in the WTCHP General Responders Consortium Polish Version

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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	334,500	0	0	334,500	0	0
Annual Time Burden (Hours)	86,250	0	0	86,250	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 clearance request.

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Annual Cost to Federal Government: $72,272

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: 11/01/2012

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