PHE Forum Generic Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 09201050)

TITLE OF INFORMATION COLLECTION: 2018 Public Health Ethics Forum

PURPOSE: This data collection will be used to obtain participant feedback about the 2018 PUBLIC HEALTH ETHICS FORUM. The one-day forum (to be held on 9/14/2018) consists of plenary and breakout sessions on various topics related to minority elders and healthy aging. The purpose of this data collection (Attachment A) is to assess participants’ satisfaction with the forum’s content and offerings, their opinion of the forum’s performance in meeting stated learning objectives, and their perceptions regarding the forum’s usefulness. The survey is voluntary and will be administered electronically via the Qualtrics survey platform. The survey was pilot tested by 3 CDC staff who were not involved with the forum planning, and the average response time was 3 minutes.

DESCRIPTION OF RESPONDENTS: The respondents will be individuals who attend the forum via in-person attendance or live webcast. The target audience for the forum includes:

• CDC staff from a variety of different CIOs;

• public health and gerontology students and faculty from local and national colleges and universities;

• professionals in the medical, social service, or policy fields who work with the elderly; and

• members of the general public who have access to the forum, including elderly persons.

We anticipate about 100 individuals to attend in-person and 200 or more to view via the live webcast. We predict a survey response rate of 30% or less which is normal for many voluntary feedback surveys. Given a predicted attendance of 300, our estimate of survey respondents is 100.

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: Denise Carty, PhD (Health Scientist, Office of Minority Health and Health Equity, CDC)

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
Individuals who attend the forum	100	5 minutes (.08 hrs)	8.33 hrs
Totals	100	5 minutes (.08 hrs)	8.33 hours

FEDERAL COST: The estimated annual cost to the Federal government is $4,150

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? [ ] Yes [X] 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?

Respondents to the survey will be selected from a list of emails of all registered participants that will be provided the day before the event for the purpose of being contacted to complete a voluntary feedback survey. No other respondent information will be included on the list – only emails. There will be no random or systematic selection of potential respondents; all forum registrants who attend the forum and voluntarily complete the survey will be included in the data collection.

Potential respondents will be invited to complete the feedback survey via an invitation email sent via Qualtrics to the list of emails of persons who registered for the forum. The invitation email (Attachment B) will include a link to access the survey in Qualtrics. Survey options in Qualtrics have been pre-configured so that all responses obtained through the survey link will be completely anonymous (Attachment C). Qualtrics will not record the email or IP address of respondents nor create cookies that can track individual respondents; therefore, no respondent contact information will be recorded.

The invitation to complete the feedback survey will be sent to forum registrants at the end of the forum, and a reminder email will be sent three business days later (Attachment B). Emails will be sent as a blind carbon copy (bcc) to registrants from a “no reply” Qualtrics email address. Due to respondent anonymity, we will not be able to distinguish the registrant emails from persons who actually attended the forum. Therefore, all forum registrants will receive an invitation to complete a feedback survey. The first question on the survey asks if the respondent attended the forum. If they respond “no,” the survey will automatically close because the data collection is intended only for persons who attended the event. Also, due to lack of respondent tracking, we won’t be able to identify those who completed a survey with the first invitation vs. those who didn’t. Therefore, all registrants who received the initial invitation will also receive a reminder email to complete the survey. However, the reminder includes instructions that those who already completed the assessment should ignore the reminder (i.e., not complete the survey a second time).

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

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

Attachment A: Feedback survey (data collection instrument)

Attachment B: Scripts (survey invitation and reminder emails)

Attachment C: Qualtrics survey options (to maintain respondent anonymity)

Attachment D: Forum agenda