GenIC Template for WTC member customer satisfaction survey

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-0953)

T ITLE OF INFORMATION COLLECTION:

The World Trade Center (WTC) Health Program Customer Satisfaction Survey

PURPOSE:

The WTC Health Program was established by the James Zadroga 9/11 Health and Compensation Act of 2010. The National Institute for Occupational Safety and Health (NIOSH) leads this Program, which provides critical medical services to those with 9/11 related health conditions. Members in the New York City metropolitan area receive care through a network of affiliated Clinical Centers of Excellence (CCE) that exclusively screen for and treat illnesses and injuries caused by or aggravated by the September 11^th terrorist attacks. Members who reside outside of this region may choose to receive care through the Nationwide Provider Network (NPN), which matches members with local healthcare providers for their 9/11 related care.

Members of the WTC Health Program are eligible for a wide range of services, such as annual health monitoring exams, treatment for certified 9/11 related conditions, and benefits counseling. NIOSH seeks to ensure that all WTC Health Program members receive the best possible medical treatment through our CCEs and the NPN. We have created a customer satisfaction survey that examines our members’ attitudes and behaviors related to the WTC Health Program. Information gathered from this survey will help us improve the patient experience and member communication.

DESCRIPTION OF RESPONDENTS:

Respondents will be members of the WTC Health Program. This group includes those who provided emergency response, recovery, and clean up services following the September 11^th terrorist attacks in New York, the Pentagon, and Shanksville, PA. It also includes those who were present in the dust cloud in New York on 9/11 and the days and weeks afterwards. The Program has approximately 77,000 members. Some of our members choose to receive information in languages other than English. This survey will be translated into Spanish, Polish, and Chinese through a certified translation service.

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: Laurie Breyer

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, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ X ] Yes [] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [X] Yes [ ] No

by SORN 09-20-0147 (76 FR 31212)

Members have the option to include their name and contact information if they would like to receive more information about the WTC Health Program. This option is strictly voluntary and will not in any way affect membership or benefits received through the Program. Storage of this optional personal contact information will be separate from the survey analysis. Survey data will not include or be linked to PII. Member requests for follow up contact with be collected by the Program’s contactor and sent to CDC/NIOSH staff through secure CDC e-mail. All staff members at CDC/NIOSH and the contractor have completed required HIPPA training. Any paper forms linking PII to response data will be destroyed as soon as the data entry occurs.

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 respondents	Participation Time	Burden
World Trade Center Health Program Member	25,000	1	15 minutes	6, 250 hours
Totals				6, 250 hours

FEDERAL COST: The estimated annual cost to the Federal government is $105,000, which includes program costs for translation, printing, and postage for return surveys.

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?

The WTC Health Program maintains a mailing list of all members and regularly communicates Program information via postal mail. We will use this list to send the customer satisfaction survey to all members with a return self-addressed stamped envelope. Members who normally receive mailings in a language other than English will also receive the survey in their preferred language (Spanish, Chinese, or Polish).

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ X ] Mail

[ ] Other, Explain

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

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

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households; (2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. of Respondents: Provide an estimate of the Number of Respondents.

Participation Time: Provide an estimate of the amount of time (in minutes) required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of Respondents and the Participation Time then divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Submit all instruments, instructions, and scripts are submitted with the request.

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