GenIC Tempate

Attachment 3

Request for Approval Under Generic Clearance for CDC Fellowship Programs Assessments (OMB Control Number: 0920-XXXX)

TITLE OF INFORMATION COLLECTION: Instruction: Provide the name of the collection that is the subject of this request.

Instruction: This form should be completed by the primary project representative at the CIO sponsoring the genIC, after consultation with the Center, Institute, or Office (CIO) PRA contact. An FTE is required to serve as the primary investigator for all information collection requests. The completed form should be routed from the PRA contact to DSEPD Information Collection Request Liaison Fátima Coronado, [email protected].

Instruction: Please provide no more than two sentences for each item in this box.

Goal of the study:

Intended use of resulting data:

Methods to be used to collect data:

Subpopulation to be studied:

How data will be analyzed:

CIO or Division PRA Contact
Name: __________________
Email: __________________
Phone: __________________

Project Representative

Instruction: Complete the fields below with information about the project lead.

Name: __________________

Title: __________________

Affiliation (CIO/Division): __________________

Email: __________________

Phone: __________________

Abbreviated Supporting Statement A

DETERMINE IF YOUR INVESTIGATION IS APPROPRIATE FOR THIS GENERIC CLEARANCE MECHANISM

Instruction: Before completing and submitting this form, first determine if the proposed investigation is appropriate for the Data Collection for CDC Fellowship Programs Generic ICR mechanism. Complete the checklist below. If you select “yes” to all criteria in Column A, the Data Collection for CDC Fellowship Programs Generic IR mechanism can be used. If you select “yes” to any criterion in Column B, the Data Collection for CDC Fellowship Programs Generic ICR mechanism cannot be used.

Column A	Column B
Information gathered is intended for CDC fellowship service improvement and program management purposes. [ ] Yes [ ] No	The investigation is conducted to contribute to generalizable knowledge. [ ] Yes [ ] No
Data collection will be completed in 90 days or less. [ ] Yes [ ] No	Data collection is expected to require greater than 90 days. [ ] Yes [ ] No
No incentive (e.g., money, reimbursement of expenses, token of appreciation) will be provided to participants. [ ] Yes [ ] No	An incentive (e.g., money, reimbursement of expenses, token of appreciation) will be provided to participants. [ ] Yes [ ] No

Did you select “yes” to all criteria in Column A?

If so, the Data Collection for CDC Fellowship Programs Generic ICR might be appropriate for your investigation. You may proceed with this form.

Did you select “yes” to any criterion in Column B?

If so, the Data Collection for CDC Fellowship Programs Generic ICR is not appropriate for your investigation. Stop completing this form now and consult your PRA contact about alternatives.

PURPOSE

Instruction: Provide a brief description of the collection purpose and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS

Instruction: Provide a brief description of the group(s) targeted for this information collection. These groups must have experience with the program.

Check all that apply.

[ ] Potential applicants or applicants

[ ] Current fellows (nonfederal employees)

[ ] Alumni

[ ] Mentors or supervisors

[ ] Employers of alumni

[ ] Other (describe): ____________________

TYPE OF COLLECTION

Instruction: Check all that apply.

[ ] Focus group

[ ] Face-to-face interview

[ ] Telephone interview

[ ] Self-administered hard copy questionnaire

[ ] Self-administered Internet questionnaire

[ ] Self-administered electronic questionnaire (e.g., fillable form)

[ ] Other (describe): ____________________

CERTIFICATION

Instruction: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

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 noncontroversial and does not raise issues of concern to other Federal agencies.

4. Information gathered will be used primarily to inform programs of efficiency and effectiveness of fellowship programs and will not be used for the purpose of substantially informing influential policy decisions.

5. 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.

6. With the exception of information needed to contact participants, personally identifiable information (PII) is collected only to the extent necessary and is not retained.

7. If this genIC requires collections of race and ethnicity data, the questions are consistent with HHS policy and standard OMB classifications.

8. A copy of the IRB approval or exemption determination with description of participation consent and secure collection, storage, and management of participant data and information is attached.

9. A currently valid OMB control number and expiration date is displayed in the upper-right corner at the beginning of the data collection instrument.

10. The following statement is displayed at the bottom of the first page of the data collection instrument or will be read to the participant prior to data collection: “Public reporting burden of this collection of information is estimated to average [number of] minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).”

    1. If the Privacy Act applies, the following statement is also included: “The Privacy Act applies to this information collection. The requested information is used toward assessment and continuous quality improvement of CDC fellowship activities and services. CDC will treat data/information in a secure manner and will not disclose, unless otherwise compelled by law.”

11. A Part II Worksheet is included in this submission.

Certified by CDC Sponsoring Program Division or CIO PRA Oversight Official:

Name: ______________________________

Date of Certification (MM/DD/YYYY): _________________

Email: _________________
Phone: _________________

To assist review, please provide answers to the following questions:

Personally Identifiable Information

1. Is personally identifiable information (PII) collected? [ ] Yes [ ] No

2. If Yes:

   1. Is the information that will be collected included in records that are subject to the Privacy Act of 1974?
      [ ] Yes [ ] No

   2. Please provide justification for collecting PII: _____________________

   3. Please describe efforts to use existing PII to avoid duplication (e.g., information from the Fellowship Management System [OMB No. 0920-0765], FedScope): ________________

   4. In advance of any data collection, the following statement will be provided directly to the participant (e.g., in a written statement on a survey tool prior to beginning a questionnaire, read to participant prior to interview): “The Privacy Act applies to this information collection. The requested information is used toward assessment and continuous quality improvement of CDC fellowship activities and services. CDC will treat data/information in a secure manner and will not disclose, unless otherwise compelled by law.”

Sensitive Questions

Instruction: If sensitive questions will be asked, provide justification and specific use.

BURDEN HOURS

Instruction: Complete Table 1 using the following column headings to calculate the burden hours for respondents.

• Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Potential applicants/applicants, (2) Current fellows (nonfederal employees), (3) Alumni, (4) Mentors or supervisors, (5) Employers of alumni, (6) Other (please describe).

• Form Name: Include the type of data collection (e.g., “Electronic survey of fellowship applicants,” “Telephone interview of recent graduates”).

• No. of Respondents: Provide an estimate of the number of respondents.

• No. of Responses per Respondent: Provide the number of times the same respondent will be contacted for data/information collection.

• Average Burden per Respondent (in hours): Provide an estimate of the amount of time required for a respondent to participate (e.g., time required to fill out a survey or participate in a focus group).

• Total Burden Hours: Provide the total burden hours by multiplying as follows:
  ([No. of Respondents] x [No. of Responses per Respondent] x [Average Burden per Respondent]) in each row. Then total the rows.

Table 1. Estimated Burden

Category of Respondent	Form Name	No. of Respondents	No. of Responses per Respondent	Average Burden per Respondent (in hours)	Total Burden Hours
Totals

FEDERAL COST

Table 2. Estimated Cost to the Government

Staff or Contractor	Average Hours	Average Hourly Rate	Total Cost
[EXAMPLE: FTE: Instrument Development, Implementation, Analysis, and Reporting (GS-13, Step 1)]
[EXAMPLE: Contractor: Instrument Development, Data Collection, Data Analysis, and Reporting (GS-13, Step 1 equivalent)]
Total

Link to U.S. Office of Personnel Management Pay Tables: https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/2016/general-schedule/.

PROJECT SCHEDULE

Instruction: Provide an estimated schedule indicating start dates, allowing sufficient time for delays and unforeseen circumstances. Sample activities and time schedules are provided; please modify as needed.

Project Time Schedule
Activity	Time Schedule
Identify whether collection of IIF is needed	At least 6 months prior to data collection to allow time to plan and collect IIF
Design methods and data collection instruments	At least 5 months prior to data collection
IRB determination	At least 4-5 months prior to data collection
Pilot test instrument (if new)	At least 4 months prior to data collection
Develop genIC request	At least 3-4 months prior to data collection
Submit genIC to ICRO (then ICRO into ROCIS)	3 months prior to data collection
Receive OMB approval for genIC	At least 1 month prior to data collection
Implement data recruitment and collection	As soon as genIC is approved or as indicated by the genIC data collection plan
Analyze data as planned	Approximately within 3 months of close of data collection
Produce technical report and lay audience fact sheets	Approximately within 6 months of close of data collection: communicate to leadership, program, or stakeholders about results and recommendations for improvement or actions
Submit findings for scientific publications, manuscript, or presentation, if applicable	6 months or more from close of data collection, if applicable

Abbreviated Supporting Statement B

Selection of targeted respondents

Instruction: Please provide a description of how you plan to identify your potential group of respondents and how you will select them.

Administration of the instrument

Instruction: Identify how the information will be collected.

1. How will you collect the information? (Check all that apply)

[ ] Electronic

[ ] Telephone

[ ] In-person

[ ] Hard copy

[ ] Other, explain: ____________________

2. Will trained interviewers or facilitators be used? [ ] Yes [ ] No [ ] N/A

Methods to maximize response

Instruction: Provide a brief description of the procedures planned to maximize response rates.

Analysis plan

Instruction: Provide a brief description of the analysis plan, including quality control procedures, and estimation procedures

Pilot testing

Instruction: Provide a brief description of pilot-test efforts.

Instruction: Describe efforts to improve or refine the instruments based on the pilot-test findings and feedback.

[ ] No changes necessary, based on pilot-test findings and feedback.

[ ] Changes (please describe): ___________________

Consultation on statistical aspects

Were outside agencies, partners, or organizations consulted on statistical aspects of the design?

[ ] Yes

[ ] No

If yes, list the following information of all persons consulted.

Name: __________________

Agency/organization (e.g., companies, state or local governments): __________________

Title: __________________

Telephone number: __________________

Email address: __________________

Please ensure that all instruments, instructions, and scripts are submitted with this request.

DATE SUBMITTED TO DSEPD INFORMATION COLLECTION REQUEST LIAISON (ICRL)

Instruction: Please indicate the date (MM/DD/YYYY) the request is submitted to the ICRL.

______________

Email the completed form to the DSEPD Information Collection Request Liaison, Fátima Coronado, at [email protected].

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