GenIC Request Form _APPLETREE Meeting 2017

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 0923-0047)
TITLE OF INFORMATION COLLECTION: Post-Meeting Survey of attendees at the
APPLETREE Meeting 2017
PURPOSE: The purpose of this data collection request is to collect feedback on the
APPLETREE grantee meeting, which will be held on May 16 – 18, 2017.
ATSDR’s Partnership to Promote Local Efforts to Reduce Environmental Exposure
(APPLETREE) program works to: 1) identify pathways of exposure to hazardous substances at
hazardous waste sites and releases, with assistance from ATSDR technical project officers
(TPOs) to address site-specific issues involving human exposure to hazardous substances; 2)
identify, implement, and coordinate public health interventions to reduce exposures to hazardous
substances which occur at levels of health concern; and 3) provide training at the state level to
promote and achieve the safe siting of child care facilities in the United States. Under the new
three-year APPLETREE cooperative agreement (Funding Opportunity Announcement No. CDCRFA-TS17-1701), eligible applicants include federally recognized American Indian/Alaska
Native tribal governments; American Indian/Alaska native tribally designated organizations;
political subdivisions of states (in consultation with states); and state and local governments or
their bona fide agents.
The proposed information collection consists of a survey designed to collect feedback from
APPLETREE awardees regarding their satisfaction with the APPLETREE Meeting 2017, which
is a meeting intended to kick off the new funding cycle for the cooperative agreement. The
information collected will be used to inform and improve planning of future similar meetings.
DESCRIPTION OF RESPONDENTS: In total, there will be approximately 200 attendees at
the APPLETREE Meeting 2017. The online survey questionnaire (Attachments B and C) will be
offered to all meeting attendees, consisting of ATSDR/APPLETREE funded grantees (State
employees), Federal Employees, and non-profit representatives. Of the 200 attendees, a total of
90 are not Federal Employees.
TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software)
[ ] Focus Group

[X] Customer Satisfaction Survey
[ ] Small Discussion 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.
1

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.
Digitally signed by Alisha Etheredge -S
DN: c=US, o=U.S. Government, ou=HHS, ou=CDC, ou=People,
0.9.2342.19200300.100.1.1=1000311055, cn=Alisha Etheredge -S
Date: 2017.05.10 15:17:46 -04'00'

Alisha Etheredge -S
Name:_________________________________________________
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
Participation
No. of
Respondents Time
90
10/60

Category of Respondent
Meeting Attendees (non-Federal)

Burden
15 hrs
15 hrs

Totals

FEDERAL COST: The estimated annual cost to the Federal government is _$250________.
This cost reflects approximately 4 hours of salary (Commissioned Officer, O-5) for one staff
person to design and implement the survey, and to draft an internal report of results.
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 survey will be emailed to all attendees of the Meeting. Attendees’ email addresses will be
used to send out the electronic survey.
Administration of the Instrument

2

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
The program will use SurveyMonkey® to collect the online survey responses. The use of
SurveyMonkey® has been reviewed and approved to be compliant with HHS IT security
standards. An IT security plan is in place for this application.
Please make sure that all instruments, instructions, and scripts are submitted with the
request.
The following attachments are included:
Attachment A: Email Invite for the APPLETREE Meeting Feedback
Attachment B: APPLETREE Post Meeting Survey_screenshot
Attachment C: APPLETREE Post Meeting Survey_text

3

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.
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.
No. of Respondents: Provide an estimate of the Number of respondents.
Participation Time: Provide an estimate of the amount of time 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 responses and the
participation time and 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.

4

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

5