Request for Approval - screener

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-1027)

TITLE OF INFORMATION COLLECTION: Provider Feedback for Chlamydia Prevention and Control Online Resources

PURPOSE: The National Chlamydia Coalition (NCC) is sponsored by the Centers for Disease Control and Prevention, (CDC). The NCC is coalition of experts and key stakeholders that seek to improve rates of chlamydia screening among sexually active young women in accordance with recommendations promulgated by CDC and the United States Preventive Services Task Force. Primary care providers will answer a short series of screening questions to evaluate their eligibility to participate in a focus group where questions will be asked regarding the use of existing online resources developed by the NCC (http://ncc.prevent.org/info/healthcare-providers) in helping providers find information on common questions about chlamydia screening they might encounter in their practice.

DESCRIPTION OF RESPONDENTS: This screener will include a brief telephone interview with providers from the following disciplines: primary care physicians (PCPs) (a mix of general practice physicians, family practice physicians, and internal medicine physicians who provide routine care for patient audiences for whom screening is recommended); nurse practitioners (NPs) and physician assistants (PAs) working in primary care settings; and, RNs in primary care settings. Participants must be doing some type of routine primary care. A total of 16 individuals will be selected to participate in one of three focus groups.

TYPE OF COLLECTION: (Check one)

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

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

[ ] Focus Group [X] Other: Screener

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:___Penny S. Loosier_____________________________________________

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ X ] Yes [ ] 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

There is no incentive for participants completing the screening questionnaire.

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Screener for eligibility	20	15 minutes	5 hrs.
Totals	20	15 minutes	5 hrs.

FEDERAL COST: The estimated annual cost to the Federal government is __$0.00____

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?

Purposive sample will be used to recruit primary care providers for participation. Members of the National Chlamydia Coalition and the National Coalition for Sexual Health will refer eligible providers. Final selection will be based on geographic dispersion, variability in practice setting, and physician/nurse designation to ensure a wide variety of provider types are represented.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[X] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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