Request for Approval

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-1026)

TITLE OF INFORMATION COLLECTION:

Children's Hospital Collaboration Forum: A Brief Survey

PURPOSE:

As part of a comprehensive domestic preparedness effort in response to the Ebola epidemic in Africa, the Centers for Disease Control and Prevention (CDC), Ebola Emergency Operations Center (EOC), Epidemiology Task Force/Children’s Task Force hosts bi-weekly calls for pediatric hospitals to form a community of practice, Children’s Hospital Collaboration Calls. These calls are intended to support hospitals as they plan for and respond to the presentation of a child suspected or confirmed to have Ebola. Each call is formatted to include: (1) a brief update from the CDC Children’s Task Force and the American Academy of Pediatrics Disaster Preparedness Advisory Council; (2) two brief audio-only presentations from either a pediatric hospital to discuss lessons learned from preparing for/responding to pediatric persons under investigation (PUIs) or from a CDC responder with updated or critical information for pediatric facilities; (3) a question and answer session that allows participants to pose questions to the presenter or CDC experts participating on the Children’s Hospital Collaboration Calls.

The purpose of this survey is to seek feedback from the participants about the format, preferred frequency of the call, usefulness of the topics discussed and identification of future topic preference. This data collection will assist the CDC Children’s Task Force improve the service provided by ensuring that calls are attended by as many pediatric facilities as possible and that the information provided during the call is relevant to the development and refinement of the hospital facility-specific plans.

An email will be sent to call participants under the following circumstances:

1. Attachment B_Children’s Hospital Collaboration Forum_Invitation Email: An invitation email will be sent to call participants with a link to the survey;

2. Attachment C_Children’s Hospital Collaboration Forum_Reminder Email: A reminder email will be sent with a link to prompt participants to complete the survey if they have not already, reminding participants of the value of their feedback on these calls.

DESCRIPTION OF RESPONDENTS:

The participants are healthcare providers from children’s hospitals, or hospitals with a pediatric capability, that are planning for or have responded to a pediatric PUI and participate on the Children’s Hospital Collaboration Calls.

TYPE OF COLLECTION: (Check one)

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

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

[ ] Focus Group [ ] Other: Registration Questionnaire and Customer Satisfaction Survey

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: Michael Bartenfeld (vdv4)

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
Pediatric healthcare provider	90	5/60	8
Totals			8 hours

FEDERAL COST: The estimated annual cost to the Federal government is $387.50

This estimate includes the following:

1. Staff hours of CDC Children’s Task Force team members for development, review and testing of the survey instruments (3 hours) – $123.75

2. Survey implementation (1 hour) - $35.00

3. Analysis of evaluation surveys – (4 hours) – 228.75

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? [X] Yes [ ] 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?

CDC’s Children’s Task Force maintains a roster of healthcare providers who are invited to the bi-weekly collaboration calls to improve facility preparedness and planning. The invitation to participate in this survey will be sent to those participating healthcare providers.

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, please explain.

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

Attachments:

Attachment A_ Children’s Hospital Collaboration Forum_Survey

Attachment B_Children’s Hospital Collaboration Forum_Invitation Email

Attachment C_Children’s Hospital Collaboration Forum_Reminder Email

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