Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Forms and Documents

Document Name	Status
EDN User Assessment Form	New
Form 0920-1071 LLS Class of 2016 Laboratory Quality Survey Form and Instruction	New
Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS) Healthcare Provider Perspective Interview Form and Instruction	New
Customer Satisfaction Survey for Soliciting Feedback on NICE Network Nursing Infection Prevention and Control In-Person Conference Sessions Form and Instruction	New
Customer Satisfaction Survey for CDC AR Isolate Bank Year 2 Form	New
Mosquito Bite Prevention Kit Feedback Form	New
Form 0920-17BL Assessment of "The Refugee Journey to Wellbeing" Exhibit at the 2016 American Society of Tropical Medicine and Hygiene (ASTMH) Conference, Atlanta, GA Form and Instruction	New
Assessment of Pilot CDC Zika Text Message Service Form and Instruction	New
Formative Evaluation of CDC Autocidal Gravid Traps in Puerto Rico Form and Instruction	New
Formative Evaluation of Zika Prevention Kits for Pregnant Women in Puerto Rico Form and Instruction	New
Ebola Global Migration Task Force (GMTF) Response After-Action Report (AAR) Survey Form and Instruction	New
Generic_Clearance_for_Qualitative_Feedback_Template_Approval_Form[1] NCEZID.docx Supplementary Document	2015-03-25
Service_Delivery_Supporting_Statement_B_NCEZID.docx Supporting Statement B	2015-03-25
Service_Delivery_Generic_Supporting_Statement_A_NCEZID revised.docx Supporting Statement A	2015-03-25

IC Document Collections

IC ID	Document Title	Status
229376	EDN User Assessment Form	New
229299	LLS Class of 2016 Laboratory Quality Survey Form and Instruction	New
229050	Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS) Healthcare Provider Perspective Interview Form and Instruction	New
227513	Customer Satisfaction Survey for Soliciting Feedback on NICE Network Nursing Infection Prevention and Control In-Person Conference Sessions Form and Instruction	New
227310	Customer Satisfaction Survey for CDC AR Isolate Bank Year 2 Form	New
226830	Mosquito Bite Prevention Kit Feedback Form	New
224315	Assessment of "The Refugee Journey to Wellbeing" Exhibit at the 2016 American Society of Tropical Medicine and Hygiene (ASTMH) Conference, Atlanta, GA Form and Instruction	New
222936	Assessment of Pilot CDC Zika Text Message Service Form and Instruction	New
221728	Customer Satisfaction Survey for CDC AR Isolate Bank Other-WORD	New
221551	Formative Evaluation of CDC Autocidal Gravid Traps in Puerto Rico Form and Instruction	New
220174	Formative Evaluation of Zika Prevention Kits for Pregnant Women in Puerto Rico Form and Instruction	New
219044	Ebola Global Migration Task Force (GMTF) Response After-Action Report (AAR) Survey Form and Instruction	New

ICR Details

OMB Control No: 0920-1071	ICR Reference No: 201503-0920-011
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 15UK
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/22/2015
	Date Received in OIRA: 04/10/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2018	36 Months From Approved
Responses	5,800	0	0
Time Burden (Hours)	3,850	0	0
Cost Burden (Dollars)	0	0	0

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

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

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 24432	04/30/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 18626	04/07/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 12

IC Title	Form No.	Form Name
Formative Evaluation of Zika Prevention Kits for Pregnant Women in Puerto Rico	NA	Intercept Interview of Pregnant Women in Puerto Rico
Formative Evaluation of CDC Autocidal Gravid Traps in Puerto Rico	NA	Focus Group Discussion Guide CDC-AGO Puerto Rico
Customer Satisfaction Survey for Soliciting Feedback on NICE Network Nursing Infection Prevention and Control In-Person Conference Sessions	NA	NICE Network Follow-Up Survey
Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS) Healthcare Provider Perspective Interview	NA, NA, NA	MECFS HP - Screener ,   MECFS HP - Individual Interview ,   MECFS HP - Dyadic Interview
Assessment of "The Refugee Journey to Wellbeing" Exhibit at the 2016 American Society of Tropical Medicine and Hygiene (ASTMH) Conference, Atlanta, GA	0920-17BL, 0920-17BL, 0920-17BL	Final Data Collection Instrument #1 ,   Data Collection Instrument # 2 ,   Final Data Collection Instrument #3 ASTHM Exhibit v3 0 smm
Mosquito Bite Prevention Kit Feedback	none, none	Mosquito Prevention Kit Feedback - English ,   Mosquito Prevention Kit Feedback - Spanish
LLS Class of 2016 Laboratory Quality Survey	0920-1071	LLS Class of 2016 Laboratory Quality Survey
Ebola Global Migration Task Force (GMTF) Response After-Action Report (AAR) Survey	NA	2014-2015 Global Migration Task Force (GMTF) Ebola response After Action Report Survey
Customer Satisfaction Survey for CDC AR Isolate Bank
Assessment of Pilot CDC Zika Text Message Service	NA	CDC Zika Text Message Service Survey
Customer Satisfaction Survey for CDC AR Isolate Bank Year 2	none	AR Isolate Bank Survey
EDN User Assessment	none, none	EDN User Survey - screenshots ,   EDN User Survey - word

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ICR Summary 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	5,800	0	0	0	5,800	0
Annual Time Burden (Hours)	3,850	0	0	0	3,850	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR.

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Annual Cost to Federal Government: $50,000

Does this IC contain surveys, censuses, or employ statistical methods? No

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

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Common Form ICR:  No

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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: 04/10/2015

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