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	Form	New	Available
Return to Learn Assessment	Form	New	Available
STEADI Phone Interview Moderator Guide 18MAY2016	Form and Instruction	New	Available
STEADI Focus Group Moderator Guide 18MAY2016	Form and Instruction	New	Available
Recruitment Screening Phone Script	Form and Instruction	New	Available
Form 0920-1009 Attachment B_Instrument	Form and Instruction	New	Available
Form 0920-1009 Attachment A_Screener	Form and Instruction	New	Available
Parent Survey - HEADS UP_Rocket Blades	Form and Instruction	New	Repair queued
Child Survey - HEADS UP_Rocket Blades	Form and Instruction	New	Available
Form 0920-1009 0920-1009 16JS Youth Violence Training	Form and Instruction	New	Available
Form 0920-1009 Instrument - VetoViolAss	Form and Instruction	New	Available
VetoViolence Survey	Form	New	Available
Website Survey	Form	New	Available
TBI Small Group Discussion Protocol	Form and Instruction	New	Available
Injury Web Survey	Form	New	Available
Discussion Guide	Form	Unchanged	Available
Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-05-01	Available
Supporting Statement B.docx	Supporting Statement B	Uploaded 2014-01-27	Available
Fast_Track_GenIC_RequestTemplate - BLANK.docx	Supplementary Document	Uploaded 2014-01-27	Available
Supporting Statement A.docx	Supporting Statement A	Uploaded 2014-01-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
224152	GenIC "Primary Care Provider - Stopping Elderly Accidents, Deaths, and Injuries (STEADI)"	Other-WORD	New
222774	GenIC Division of Violoence Prevention Webinar Participant Feedback	Other-WORD	New
221710	VetoViolence Usability Testing	Form	New	Survey
221572	Assessing "Return to Learn" Programs	Form	New	Return to Learn Assessment
221538	Stopping Elderly Accidents, Deaths, and Injuries (STEADI) - Focus Groups	Form and Instruction	New	STEADI Phone Interview Moderator Guide 18MAY2016
221538	Stopping Elderly Accidents, Deaths, and Injuries (STEADI) - Focus Groups	Form and Instruction	New	STEADI Focus Group Moderator Guide 18MAY2016
221538	Stopping Elderly Accidents, Deaths, and Injuries (STEADI) - Focus Groups	Form and Instruction	New	Recruitment Screening Phone Script
221119	Assessing the Effectiveness of HEADS UP Message	Form and Instruction	New	Attachment B_Instrument
221119	Assessing the Effectiveness of HEADS UP Message	Form and Instruction	New	Attachment A_Screener
220790	Customer Service - HEADS UP Rocket Blades	Form and Instruction	New	Parent Survey - HEADS UP_Rocket Blades
220790	Customer Service - HEADS UP Rocket Blades	Form and Instruction	New	Child Survey - HEADS UP_Rocket Blades
220543	Customer feedback interviews with state-level implementers of "Return to Learn"	Other-WORD	New
219607	Youth Violence Training and Technical Assistance Satisfaction Survey	Form and Instruction	New	0920-1009 16JS Youth Violence Training
219366	Division of Violence Prevention grantee individual interviews regarding VetoViolence.cdc.gov	Form and Instruction	New	Instrument - VetoViolAss
215501	VetoViolence Online Survey	Form	New	VetoViolence Survey
213980	Injury Website Online Survey – Second request	Form	New	Website Survey
213822	Customer Feedback of state-level traumatic brain injury prevention workers	Form and Instruction	New	TBI Small Group Discussion Protocol
213602	Injury Website Online Survey	Form	New	Injury Web Survey
212036	WISQARS Home Page Survey	Other-WORD	New
211588	WISQARS Mobile App Online Survey	Other-WORD	New
211297	Customer Satisfaction (User Feedback) of a Mobile Application to Improve Preparation and Response to a Terrorist Event or Other Mass Casualty Event	Other-WORD	Unchanged
211074	WISQARS Discussion Groups	Form	Unchanged	Discussion Guide

ICR Details

OMB Control No: 0920-1009	ICR Reference No: 201405-0920-002
Status: Historical Active	Previous ICR Reference No: 201401-0920-008
Agency/Subagency: HHS/CDC	Agency Tracking No: 21359
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/07/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/05/2014
Terms of Clearance: Previous Terms continue: 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	03/31/2017	03/31/2017	03/31/2017
Responses	228,000	0	180,000
Time Burden (Hours)	104,250	0	56,250
Cost Burden (Dollars)	0	0	0

---

Abstract: This collection of information is necessary to enable the Agency to garner customer and stateholder feedback in an efficient, timely manner, in accordance with our commitment to improving service elivery. The informaiton collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the Agency's programs.

---

Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

Citations for New Statutory Requirements: None

---

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

---

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:
	79 FR 4909	01/30/2014
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 18

table that charts list of burden

IC Title	Form No.	Form Name
Assessing "Return to Learn" Programs	none	Return to Learn Assessment
Assessing the Effectiveness of HEADS UP Message	0920-1009, 0920-1009	Attachment A_Screener ,   Attachment B_Instrument
Customer Feedback of state-level traumatic brain injury prevention workers	none	TBI Small Group Discussion Protocol
Customer Satisfaction (User Feedback) of a Mobile Application to Improve Preparation and Response to a Terrorist Event or Other Mass Casualty Event
Customer Service - HEADS UP Rocket Blades	NA, NA	Child Survey - HEADS UP_Rocket Blades ,   Parent Survey - HEADS UP_Rocket Blades
Customer feedback interviews with state-level implementers of "Return to Learn"
Division of Violence Prevention grantee individual interviews regarding VetoViolence.cdc.gov	0920-1009	Instrument - VetoViolAss
GenIC "Primary Care Provider - Stopping Elderly Accidents, Deaths, and Injuries (STEADI)"
GenIC Division of Violoence Prevention Webinar Participant Feedback
Injury Website Online Survey	None	Injury Web Survey
Injury Website Online Survey – Second request	none	Website Survey
Stopping Elderly Accidents, Deaths, and Injuries (STEADI) - Focus Groups	NA, NA, NA	Recruitment Screening Phone Script ,   STEADI Focus Group Moderator Guide 18MAY2016 ,   STEADI Phone Interview Moderator Guide 18MAY2016
VetoViolence Online Survey	none	VetoViolence Survey
VetoViolence Usability Testing	none	Survey
WISQARS Discussion Groups	none	Discussion Guide
WISQARS Home Page Survey
WISQARS Mobile App Online Survey
Youth Violence Training and Technical Assistance Satisfaction Survey	0920-1009	0920-1009 16JS Youth Violence Training

---

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	228,000	180,000	0	48,000	0	0
Annual Time Burden (Hours)	104,250	56,250	0	48,000	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: Program underestimated the types and number of service delivery feedback projects they expect to do.

---

Annual Cost to Federal Government: $60,000

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

---

Common Form ICR:  No

---

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: 05/05/2014

---