Survey1template _VitalSignsv2

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-0956)

TITLE OF INFORMATION COLLECTION:

Vital Signs Survey

PURPOSE:

Vital Signs is an important program at CDC. It is a call to action each month concerning a single, important public health topic. The program consists of several parts, including (1) an MMWR Early Release the first Tuesday of every month; (2) A professionally designed Fact Sheet for consumer audiences, a dedicated website that mirrors the Fact Sheet on the topic; (3) a media release; and (4) a series of announcements via social media tools (Twitter, Facebook, etc.) CDC believes that by focusing on a single topic using multiple media devices, the states might better identify these health problems in their area and work towards their improvement.

The Vital Signs monthly survey is administered via a feedback button/tab on the main Vital Signs webpage. The survey is administered to improve Vital Signs for the general public and to make sure we are providing the right information to the right audience. It is a way to assess customer satisfaction with the communication tool. From the survey we find out the following: how the individual is using the Vital Signs material, how well it provides information for the consumer to take action on the health topic, how well the health issue is explained, and how they found out about Vital Signs.  

DESCRIPTION OF RESPONDENTS:

This is a voluntary survey. The participants generally fall into the following groups: individual interested in health issues, patient/friend or family member interested in health issues, state/county/local public health professional, physician, nurse/physician’s assistant/nurse practitioner, CDC employee/contractor, scientist/researcher, policymaker/legislator/or staff, other (generally students, college professors, etc.).

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[x ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[] Focus Group [ ] Other: ______________________

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

3. The collection is non-controversial and does not raise issues of concern to other federal agencies.

4. The results are not intended to be disseminated to the public.

5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

Name:____Sharon McAleer____________________________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [x ] No

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [ x ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [x ] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden Hours
General Consumer	1000	7/60	117
Health Care Providers	1000	7/60	117
Public Health Professionals	1000	7/60	117
Totals	3000		351

FEDERAL COST: The estimated annual cost to the Federal government is ___$17,500_________

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [ ] Yes [x] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

• It is voluntary. Whoever chooses to click on the feedback tab has the option to take the survey or decline it.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[x] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [x] No

5