Template Request

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-0974)

TITLE OF INFORMATION COLLECTION: Applicability and Use of The Community Guide Among National Association of County and City Health Officials (NACCHO) Members

PURPOSE:

The purpose of this project is to gather baseline data to assess Task Force Liaison (TFL) organizations level of awareness and how TFLs use, share, and prefer to receive support in using The Community Guide. This project is part of an overall goal to assess the awareness and use of The Community Guide (website) among TFL organizations.

DESCRIPTION OF RESPONDENTS:

Members of NACCHO inclusive of local health department staff: community health workers, health educators, public health managers, registered nurses, administrative personnel, and other health professionals.

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: Anita Alston Ellis

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 [X] 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

We estimate it will take no more than 15 minutes to complete the survey. We are seeking to collect feedback from approximately 6300 NACCHO members. Based on preliminary conversations with NACCHO staff regarding previous survey response rates and this survey being voluntary, we anticipate 300 NACCHO members to respond, resulting in total of 75 burden hours. The table below displays this breakdown.

Category of Respondent		No. of Respondents	Participation Time	Burden (hours)
Total # County and city health officials we anticipate to respond		300	15	75
Total # of burden hours				75

FEDERAL COST: The estimated annual cost to the Federal government is $3,620. The table below includes the estimated amount of time spent and annual cost for one FTE and one non-FTE Community Guide Branch staff.

Category of Employees	No. of Employees	Hourly Rate	No. of Hours	Annual Cost
FTE staff	1	43	60	2580
Non-FTE staff	1	26	40	1040
Totals	2	69	100	3620

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 ] Y [ ] 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?

CDC has drafted the introductory and reminder email with the survey link that will be sent to NACCHO staff (see supporting documents provided). NACCHO staff will distribute the survey to member listervs via their internal email system (MagnetMail). Responses will be collected and exported via the Survey Monkey tool managed by CDC however are not linked to NACCHO member’s listservs. CDC will analyze the collected data.

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.

Attachments include:

Recruitment email

Follow-up email

Survey instrument

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