GenIC Request

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 0923-0047)
TITLE OF INFORMATION COLLECTION: Choose Safe Places for Early Care and
Education Survey
PURPOSE: The purpose of the survey is to collect feedback from Agency for Toxic Substances
and Disease Registry’s (ATSDR’s) cooperative agreement partners on: 1) the utility of resources
provided over the past year relating to creation of Choose Safe Places for Early Care and
Education (CSPECE) programs and 2) the need for specific resources for the upcoming year.
CSPECE is a new initiative for cooperative agreement partners centered on safely siting
childcare centers to prevent exposures to toxic substances. It is essential that we survey
cooperative agreement partners to understand the utility of previous resources and need for
additional resources to provide relevant resources that best address identified needs. Data will be
collected through Survey Monkey using Attachment B and Attachment C.
DESCRIPTION OF RESPONDENTS: ATSDR Cooperative Agreement partner staff.
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.
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.

Padmaja Vempaty -S Date: 2018.05.24 09:20:06 -04'00'
Name:________________________________________________
Digitally signed by Padmaja Vempaty -S

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
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BURDEN HOURS
Category of Respondent

Burden

State, local, or tribal governments

No. of
Participation
Respondents Time
25
10/60

Totals

25

4

10/60

4

COST TO RESPONDERS: The estimated annual cost to responders is $133.48. (Based on
Environmental Health Scientist job position retrieved from
https://www.bls.gov/oes/current/oes_nat.htm at a rate of $33.37/hour).
FEDERAL COST: The estimated annual cost to the Federal government is $6,400.
(Based on 0.05 FTE).
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 maintains a mailing list of cooperative agreement partners from state health
organizations/agencies. All staff on the cooperative agreement team and their associated official
email address are included in this mailing list. All partners are required to develop a CSPECE as
part of their existing Notice of Funding Opportunity (NOFO).
Based on the above mailing list, the Primary Investigator from each state will be invited to
participate via email (Attachment A).

Administration of the Instrument
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

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

1) AttA Email Invitation for CSPECE
2) AttB CSPECE Survey (screenshots)
3) AttC CSPECE Survey (text)

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