Request for Approval

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-1050)

TITLE OF INFORMATION COLLECTION: Tuberculosis (TB) Training and Education Needs Assessment of the U.S.-affiliated Pacific Islands and Hawaii

PURPOSE: The purpose of this activity is to identify TB training and education needs, priorities, and existing resources of Hawaii and the U.S.-affiliated Pacific Islands (i.e., American Samoa, Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, the Republic of Palau, and the Republic of the Marshall Islands).

The questionnaire will be administered online using SurveyMonkey. A link to the questionnaire will be emailed to TB program staff in Hawaii and the U.S.-affiliated Pacific Islands. A printable version of the questionnaire will also be emailed to TB program staff so that it can be completed by individuals who do not have reliable access to the internet.

The questionnaire contains demographic questions, such as job title, percentage of time working on TB activities, and number of years working in TB. The questionnaire also contains a series of Likert-scale questions that ask individuals to indicate how much training they need regarding TB topics such as diagnosis, clinical management, treatment, and programmatic activities. Other questions include the number of TB trainings attended over the past 12 months, barriers to attending trainings, and preferred formats for trainings and education materials.

Collection of this information will help CDC develop a plan to address TB training and education needs in Hawaii and the U.S.-affiliated Pacific Islands. Conducting a needs assessment will help ensure that training and education efforts are appropriate for the target audience.

DESCRIPTION OF RESPONDENTS: Individuals taking part in the needs assessment will include TB program staff and other health care workers involved in TB control activities in Hawaii and the U.S.-affiliated Pacific Islands (for example, persons working on TB in hospitals, laboratories, private clinics, and community health centers).

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:_ Segerlind, Sarah (CDC/OID/NCHHSTP) Email: [email protected]

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

Category of Respondent	No. of Respondents	Participation Time	Burden
State, local, or tribal governments	200	15 minutes	50 hours
Totals	200	15 minutes	50 hours

FEDERAL COST: The estimated annual cost to the Federal government is: $5,000.

This estimate is based on the number of hours for survey development, data collection, data analysis, and report preparation.

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 respondents will include TB program staff in Hawaii and the U.S.-affiliated Pacific Islands that are funded through the CDC Cooperative Agreement (PS13-1301). The CDC Division of TB Elimination Program Consultant for Hawaii and the U.S.-affiliated Pacific Islands will assist with identifying and providing email addresses for TB program staff in these jurisdictions.

Health care workers involved in TB control activities (for example, hospital staff, private providers, and staff at community health centers) in Hawaii and the U.S.-affiliated Pacific islands will also be included in the needs assessment. These respondents will be identified by TB program staff.

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

[X] Other, Explain

For respondents who do not have reliable access to the internet, a printed questionnaire will be provided. The printable version of the questionnaire will be emailed to TB program staff who will then distribute it to their TB control partners. TB program staff will scan and email completed questionnaires to CDC.

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. Include discussion of recruitment/contact method, consent, etc. 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.

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