GenIC Request Form

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 0920-1050)
TITLE OF INFORMATION COLLECTION: Post-Meeting Survey of attendees at the 2018
Childhood Lead Poisoning Prevention Annual Cooperative Agreement Recipients’ Meeting
PURPOSE:
The purpose of this data collection request is to collect feedback on the Childhood Lead
Poisoning Prevention Program Annual Cooperative Agreement Recipients’ Meeting, which was
held December 4-7, 2018.
The primary responsibility of CDC’s Childhood Lead Poisoning Prevention Program (CLPPP) is
to develop programs and policies to prevent childhood lead poisoning. CLPPP funds 48 state
and local health departments for lead prevention and surveillance activities under cooperative
agreements CDC-RFA-EH17-1701PPHF and CDC-RFA-EH14-1408PPHF.
The proposed information collection consists of a survey designed to collect feedback from
attendees of the 2018 Childhood Lead Poisoning Prevention Program Annual Cooperative
Agreement Recipients’ Meeting. The meeting was held to provide face-to-face opportunities for
cooperative agreement recipients and national partners to discuss the ongoing efforts to prevent
childhood lead poisoning. The information collected will be used by CLPPP to improve
logistics, communication, and quality of future cooperative agreement recipient meetings.
DESCRIPTION OF RESPONDENTS:
In total, there were approximately 150 attendees at the 2018 Childhood Lead Poisoning
Prevention Program Annual Cooperative Agreement Recipients’ Meeting. The online survey
questionnaire (Attachment B) will be offered to all meeting attendees, consisting of funded
recipients and Federal Employees. Of the 150 attendees, 125 are not expected to be Federal
Employees (state, local, and territorial health department 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.
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.
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Digitally signed by Alisha

Alisha Etheredge -S Etheredge -S

Date: 2018.12.10 20:29:20 -05'00'
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
Category of Respondent

No. of
Participation
Respondents Time
125
5/60

Meeting Attendees (non-Federal grantees and
stakeholders)
Meeting Attendees (Federal stakeholders)
Totals

25

5/60

Burden
10.5 hours
2 hours
12.5 hours

FEDERAL COST: The estimated annual cost to the Federal government is $145.00. This cost
reflects approximately 4 hours of salary (GS-13 equivalent) for one staff person to design and
implement the survey, and 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?
[] 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?
All meeting attendees will be surveyed; there will be no sampling plan for selecting from this
group. The program has a list of email addresses of all meeting attendees and will use this list to
send the survey invitation 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
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[ ] Telephone
[ ] In-person
[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ ] Yes [ X ] No
The program will use SurveyMonkey® to collect online responses. The use of SurveyMonkey®
has been reviewed and approved to be compliant with HHS IT security standards.
Please make sure that all instruments, instructions, and scripts are submitted with the
request.
The following attachments are included:
Attachment A: Email Invite for 2018 Lead Poisoning Prevention Recipient Meeting Survey
Attachment B: Lead Poisoning Prevention Recipient Meeting Survey_screenshot
Attachment C: Lead Poisoning Prevention Recipient Meeting Survey_text

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