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

Forms and Documents

Document Name	Status
Survey to Improve Worker Notification Efforts #3 Form	New
Survey to Improve Worker Notification Efforts Form	New
Fatigue Prevention Training Module Customer Satisfaction and Feedback Survey Form and Instruction	New
Form 0920-0953 The World Trade Center Health Program Customer Satisfaction Survey Form and Instruction	New
Long Island WTC Health Program Survey Form	New
North Shore LIJ Customer Satisfaction Survey Form and Instruction	New
Form 0920-0953 The World Trade Center Health Program for Responders at Rutgers University Customer Satisfaction Survey Form and Instruction	New
World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey (Spanish and Polish versions) Form and Instruction	New
Manual of Analytical Methods Customer Satisfaction Survey Form	New
Generic_Clearance_Submission_Template[1].doc Supplementary Document	2012-11-01
NIOSH Part SS-B.docx Supporting Statement B	2012-11-01
NIOSH Part SS-A.docx Supporting Statement A	2012-11-01

IC Document Collections

IC ID	Document Title	Status
216450	Survey to Improve Worker Notification Efforts #3 Form	New
216300	Survey #2 Other-WORD	New
216239	Survey to Improve Worker Notification Efforts Form	New
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
212365	The World Trade Center Health Program Customer Satisfaction Survey Form and Instruction	New
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
209700	North Shore LIJ Customer Satisfaction Survey Form and Instruction	New
209666	The World Trade Center Health Program for Responders at Rutgers University Customer Satisfaction Survey Form and Instruction	New
208833	World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey (Spanish and Polish versions) Form and Instruction	New
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

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
	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.

	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

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

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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	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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