Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIOSH 2)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0953 Focus Group Discussion Guide Attachment A	Form and Instruction	New	Available
Form 0920-0953 PPE (Personal Protective Equipment) Survey	Form	New	Available
Form 0920-0953 Member Survey - 2018	Form and Instruction	New	Available
Form 0920-0953 PPE Survey	Form	New	Available
Form 0920-0953 National Occupational Research Agenda (NORA)	Form and Instruction	New	Repair queued
World Trade Center Health Program Member Feedback Questionnaire	Form	New	Available
Form 0920-0953 5-WB2811-Evaluation (3)	Form and Instruction	New	Repair queued
Form 0920-17EO NORA AFF SC questionnaire_Appendix 2	Form and Instruction	New	Available
NORA Oil and Gas Research Agenda Questionnaire	Form and Instruction	New	Available
World Trade Center Health Program Member Questionnaire - Telephone Survey	Form and Instruction	New	Available
World Trade Center Health Program Member Questionnaire - Paper Survey	Form and Instruction	New	Available
Patient Survey	Form	New	Available
WTCHP Call Center Stisfaction Survey - Pharmacists	Form and Instruction	New	Available
WTCHP Call Center Stisfaction Survey - Health Providers	Form and Instruction	New	Available
WTCHP Call Center Stisfaction Survey - Clinical Centers of Excellence	Form and Instruction	New	Available
WTCHP Call Center Stisfaction Survey - Program Members	Form and Instruction	New	Repair queued
Form 0920-0953 Queens2018update	Form and Instruction	New	Repair queued
Patient Satisfaction Survey	Form and Instruction	New	Available
Survey	Form	New	Repair queued
Survey 2 Screenshots	Form	New	Available
Survey #3	Form	New	Available
Survey #1	Form	New	Available
Customer Satisfaction Survey	Form	New	Available
Generic_Clearance_Submission_Template[1].doc	Supplementary Document	Uploaded 2012-11-01	Available
NIOSH Part SS-B.docx	Supporting Statement B	Uploaded 2015-07-09	Available
NIOSH Part SS-A 7 9 15.docx	Supporting Statement A	Uploaded 2015-07-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
231646	Three Occupation-specific Units for the Workplace Violence Course: Focus Group Discussions for the Stand-alone Facilities, Home Health/Social Services, and Emergency Responder units	Form and Instruction	New	Focus Group Discussion Guide Attachment A
231621	Assessing and Evaluating the Effectiveness of Hazard Recognition and Risk Assessment Interventions	Other-WORD	New
230826	Assessment of Personal Protective Equipment Information Database Needs and Capabilities	Form	New	PPE (Personal Protective Equipment) Survey
230585	SUNY – Stony Brook CCE WTC Health Program Customer Satisfaction Survey	Form and Instruction	New	Member Survey - 2018
230190	Assessment of Personal Protective Equipment Information Database Needs and Capabilities	Form	New	PPE Survey
229780	NORA Services Sector Council Questionnaire	Form and Instruction	New	National Occupational Research Agenda (NORA)
226088	The World Trade Center (WTC) Health Program Customer Satisfaction Survey	Form	New	World Trade Center Health Program Member Feedback Questionnaire
226013	WTCH Routine Customer Feedback	Form and Instruction	New	5-WB2811-Evaluation (3)
225018	NIOSH Center for Motor Vehicle Safety Needs Assessment and Audience Analysis	Other-WORD	New
224575	NORA Agriculture Forestry and Fishing Council	Form and Instruction	New	NORA AFF SC questionnaire_Appendix 2
223400	NORA Oil and Gas Extraction Council Questionnaire	Form and Instruction	New	NORA Oil and Gas Research Agenda Questionnaire
222175	User Feedback Questionnaire for ERHMS Info Manager	Other-WORD	New
220862	Total Worker Health Capacity Building Letter	Other-WORD	New
220544	Worker Notification Feedback Survey	Other-WORD	New
220442	NORA Agriculture, Forestry, and Fishing Sector Council Feedback through Focus Groups	Other-Focus Group Guide	New
220438	NORA Agriculture, Forestry, and Fishing Sector Council Feedback through Informant Interviews	Other-Interview Guide	New
219531	World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey	Form and Instruction	New	World Trade Center Health Program Member Questionnaire - Telephone Survey
219531	World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey	Form and Instruction	New	World Trade Center Health Program Member Questionnaire - Paper Survey
219421	WTC Health Program for Responders at Rutgers University	Form	New	Patient Survey
219420	The World Trade Center (WTC) Health Program Call Center Satisfaction Survey	Form and Instruction	New	WTCHP Call Center Stisfaction Survey - Pharmacists
219420	The World Trade Center (WTC) Health Program Call Center Satisfaction Survey	Form and Instruction	New	WTCHP Call Center Stisfaction Survey - Health Providers
219420	The World Trade Center (WTC) Health Program Call Center Satisfaction Survey	Form and Instruction	New	WTCHP Call Center Stisfaction Survey - Clinical Centers of Excellence
219420	The World Trade Center (WTC) Health Program Call Center Satisfaction Survey	Form and Instruction	New	WTCHP Call Center Stisfaction Survey - Program Members
219316	North Shore LIJ Customer Satisfaction Survey	Form and Instruction	New	Queens2018update
219258	Long Island World Trade Center Health Program Customer Satisfaction Survey	Form and Instruction	New	Patient Satisfaction Survey
219255	The Nationwide Provider Network Customer Satisfaction Survey	Form	New	Survey
217876	Improve Worker Notification Efforts: Survey #2	Form	New	Survey 2 Screenshots
217866	Improve Worker Notification Efforts: Survey #3	Form	New	Survey #3
217864	Improve Worker Notification Efforts: Survey #1	Form	New	Survey #1
217668	North Shore LIJ Customer Satisfaction Survey	Form	New	Customer Satisfaction Survey

ICR Details

OMB Control No: 0920-0953	ICR Reference No: 201505-0920-003
Status: Historical Active	Previous ICR Reference No: 201211-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0953
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIOSH 2)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/17/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/04/2015
Terms of Clearance: 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	07/31/2018	36 Months From Approved	12/31/2015
Responses	229,800	0	334,500
Time Burden (Hours)	57,975	0	86,250
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information is necessary to enable the CDC/NIOSH to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The types of collections that this generic clearance covers include, but are not limited to: Customer comment cards/complaint forms, Small discussion groups, Focus Groups of customers, potential customers, delivery partners, or other stakeholders, Cognitive laboratory studies, such as those used to refine questions or assess usability of a website, Qualitative customer satisfaction surveys (e.g., post-transaction surveys; opt-out web surveys) and In-person observation testing (e.g., website or software usability tests).

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Authorizing Statute(s): PL: Pub.L. 91 - 596 20 Name of Law: Occupational Safety and Health Act of 1970
  

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 29710	05/22/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 26

table that charts list of burden

IC Title	Form No.	Form Name
Assessing and Evaluating the Effectiveness of Hazard Recognition and Risk Assessment Interventions
Assessment of Personal Protective Equipment Information Database Needs and Capabilities	0920-0953	PPE (Personal Protective Equipment) Survey
Assessment of Personal Protective Equipment Information Database Needs and Capabilities	0920-0953	PPE Survey
Improve Worker Notification Efforts: Survey #1	none	Survey #1
Improve Worker Notification Efforts: Survey #2	none	Survey 2 Screenshots
Improve Worker Notification Efforts: Survey #3	none	Survey #3
Long Island World Trade Center Health Program Customer Satisfaction Survey	NA	Patient Satisfaction Survey
NIOSH Center for Motor Vehicle Safety Needs Assessment and Audience Analysis
NORA Agriculture Forestry and Fishing Council	0920-17EO	NORA AFF SC questionnaire_Appendix 2
NORA Agriculture, Forestry, and Fishing Sector Council Feedback through Focus Groups
NORA Agriculture, Forestry, and Fishing Sector Council Feedback through Informant Interviews
NORA Oil and Gas Extraction Council Questionnaire	NA	NORA Oil and Gas Research Agenda Questionnaire
NORA Services Sector Council Questionnaire	0920-0953	National Occupational Research Agenda (NORA)
North Shore LIJ Customer Satisfaction Survey	none	Customer Satisfaction Survey
North Shore LIJ Customer Satisfaction Survey	0920-0953	Queens2018update
SUNY – Stony Brook CCE WTC Health Program Customer Satisfaction Survey	0920-0953	Member Survey - 2018
The Nationwide Provider Network Customer Satisfaction Survey	none	Survey
The World Trade Center (WTC) Health Program Call Center Satisfaction Survey	NA, NA, NA, NA	WTCHP Call Center Stisfaction Survey - Program Members ,   WTCHP Call Center Stisfaction Survey - Clinical Centers of Excellence ,   WTCHP Call Center Stisfaction Survey - Health Providers ,   WTCHP Call Center Stisfaction Survey - Pharmacists
The World Trade Center (WTC) Health Program Customer Satisfaction Survey	N/A	World Trade Center Health Program Member Feedback Questionnaire
Three Occupation-specific Units for the Workplace Violence Course: Focus Group Discussions for the Stand-alone Facilities, Home Health/Social Services, and Emergency Responder units	0920-0953	Focus Group Discussion Guide Attachment A
Total Worker Health Capacity Building Letter
User Feedback Questionnaire for ERHMS Info Manager
WTC Health Program for Responders at Rutgers University	none	Patient Survey
WTCH Routine Customer Feedback	0920-0953	5-WB2811-Evaluation (3)
Worker Notification Feedback Survey
World Trade Center (WTC) Health Program General Responder Consortium (GRC) Outreach Survey	NA, NA	World Trade Center Health Program Member Questionnaire - Paper Survey ,   World Trade Center Health Program Member Questionnaire - Telephone Survey

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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	229,800	334,500	0	-104,700	0	0
Annual Time Burden (Hours)	57,975	86,250	0	-28,275	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Decrease in Response/Burden Hours is based on the number of collections the program expects to conduct over the requested period for this clearance.

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Annual Cost to Federal Government: $112,000

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

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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: 06/04/2015

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