Completed Template for Agency Service Delivery Submissions

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 0923-0047)
TITLE OF INFORMATION COLLECTION: Customer Feedback on ATSDR’s Coping with
Stress Fact Sheet
PURPOSE: ATSDR is better able to serve the public when it gains feedback from customers on
its products. The purpose of this information collection is for ATSDR to improve customer
service by learning how people use ATSDR’s “Coping with the Stress that Environmental
Contamination Can Cause” Fact Sheet. ATSDR will use a feedback form and follow up phone
interview (Appendix A) to learn about state, local, and tribal health department staff experiences
sharing the fact sheet with members of the public. Based on this feedback, ATSDR will modify
the fact sheet (Appendix B) and/or the additional materials to guide and support effective use of
the fact sheet (Appendix C). Through this process ATSDR will be able to better serve its
customers and protect the health of communities.
DESCRIPTION OF RESPONDENTS: State, local, and tribal health department personnel
who have shared ATSDR’s “Coping with the Stress that Environmental Contamination Can
Cause” Fact Sheet with community members. ATSDR will distribute the fact sheet and feedback
form to these groups through a webinar and targeted email outreach.
TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software)
[ ] Focus Group

[ ] Customer Satisfaction Survey
[ ] Small Discussion Group
[X] Other - Feedback Form and Phone
Interview

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.

Alisha Etheredge -S

Digitally signed by Alisha Etheredge -S
Date: 2017.08.02 11:23:59 -04'00'

Name: __________________________________________
Stephanie Davis, NCEH/ATSDR PRA Coordinator

1

To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [X] No
Respondents are state, local, and tribal health department personnel responding in their
official capacity. Contact information is needed to complete follow up phone interviews.
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

Webinar attendees
Totals

20

Participation
Time (in hrs.)
20/60

Burden (in hrs.)

Respondents will take 5 minutes to complete the form and 15 minutes to complete the interview.
[20 x 5/60 = 2 hours and 20 x 15/60 = 5 hours. Total time burden requested is 7 hours.]
FEDERAL COST: The estimated annual cost to the Federal government is $331.73. The cost
estimate follows. Managing this information collection will take 1 FTE one hour to conduct the
webinar session, and six hours to distribute and collect the forms, conduct the phone interviews,
and collate responses for agency use (GS-14 Step-5 hourly wage rate is $47.39 from
https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salarytables/pdf/2016/GS_h.pdf) [7 x $47.39 = $331.73].

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?
ATSDR will distribute the fact sheet and feedback form to state, local, and tribal health
department personnel through a webinar and targeted email outreach. ATSDR will ask
them to fill out the feedback form if they use the fact sheet in a community setting.
Attendees may return a hardcopy response or electronic copy via email, and indicate if

2

7

they will participate in a short telephone interview. ATSDR assumes that 100% of fact
sheet users will fill out the form and agree to the interview.
Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[ ] Web-based or other forms of Social Media
[X] Telephone
[ ] In-person
[X] Mail
[X] Other, Explain: Respondents will fill out the feedback form electronically and send it
to ATSDR by email, and then participate in qualitative telephone interviews.
2. Will interviewers or facilitators be used? [X] Yes [ ] No
ATSDR staff will follow up with respondents by telephone to discuss their feedback and
ways to improve the materials.
Please make sure that all instruments, instructions, and scripts are submitted with the
request.
The following attachments are included:
Appendix A. Stress Fact Sheet Feedback Form and Telephone Interview
• A.1. Recruitment Email
Appendix B. ATSDR’s “Coping with the Stress that Environmental Contamination Can
Cause” Fact Sheet
Appendix C. Additional materials
• C.1. Tips on using the “Coping with Stress” Fact Sheet for ATSDR & Health
Department staff
• C.2. Additional reading about stress
Appendix D. ATSDR Research Determination

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

4