Request for Approval

Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIOSH)” (OMB Control Number: 0920-0940)

TITLE OF INFORMATION COLLECTION: Local Health Department and the HHE Program: Brochure Survey

PURPOSE:

The Health Hazard Evaluation (HHE) program will collect data from local health department directors regarding their communication preferences for program information. We will send our program brochure, “Local Health Departments and the NIOSH Health Hazard Evaluation Program: Working Together,” to local health department directors either through the postal service or electronically, and then we will send a customer satisfaction survey the following week. The data collection will be done using a web-based system. We are requesting approval for clearance to assess the recipients’ 1) opinions about the method of delivery of the brochure 2) understanding of the key features of the HHE Program, and 3) attitudes toward the program and intentions to use HHE services after reading the brochure.

Results of the evaluation will be used to improve our communication methods with local health departments, enhance the impact and effectiveness of the HHE program’s activities and products, and, ultimately, enhance the HHE Program’s ability to help ensure safe and healthy work places for all American workers.

DESCRIPTION OF RESPONDENTS: Respondents are local health department directors or their designees.

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: ______________________

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: Jennifer Tyrawski, PhD

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 [ ] 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	No. of Responses per Respondent	Avg. Burden per response(in hours)	Total Burden in Hours
Local health officers or their designees	500	1	10/60	83
Totals				83

FEDERAL COST: The estimated annual cost to the Federal government is $4759.17

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?

We have a list of 500 local health department designees who have not previously been contacted by the HHE program. Both email addresses and postal addresses were obtained. We plan to randomly select half of the designees to receive the brochure through email and half to receive the brochure through the postal service.

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

2