CDC/ATSDR Formative Research and Tool Development

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-1154 Construction Workers Focus Groups (SPANISH)	Form and Instruction	New	Available
Form 0920-1154 Construction Workers Focus Groups (ENGLISH)	Form and Instruction	New	Available
Form 0920-1154 Construction Supervisor/Foreman Focus Group	Form and Instruction	New	Available
Form 0920-1154 Construction Industry Executive/Decision-Maker In-Depth Interviews	Form and Instruction	New	Available
Form 0920-1154 Survey Disaster Planners	Form and Instruction	New	Available
Interview sign-up	Form	New	Available
Focus group demographic survey	Form	New	Available
Interview demographic survey	Form	New	Available
Survey prenotice	Form	New	Available
Survey - word	Form	New	Available
Survey	Form	New	Available
Survey (content)	Form and Instruction	New	Available
Initial Screen Shot of the Web-based Survey (with OMB control information)	Form and Instruction	New	Available
Screener	Form and Instruction	New	Available
Focus Group Guide: Minority Men Diagnosed with Type 2 Diabetes	Form and Instruction	New	Available
Focus Group Guide: Minority Men at Risk for Type 2 Diabetes	Form and Instruction	New	Available
Form 0920-1154 Key Informant Interview Plan	Form and Instruction	New	Available
Form 0920-1154 Provider Screener and Online Survey	Form	New	Available
Form 0920-1154 Consent Form Women In-Depth Interview	Form and Instruction	New	Available
Form 0920-1154 Consent Form Provider In-Depth Interview	Form and Instruction	New	Available
Form 0920-1154 Consent Form Provider (Online Survey)	Form and Instruction	New	Available
Recruitment Follow-up Contact	Form and Instruction	New	Available
Recruitment Screener	Form and Instruction	New	Available
Form 0920-1154 Questionnaire Content	Form and Instruction	New	Available
Form 0920-1154 FSAP User Experience Survey	Form	New	Available
Form 0920-1154 FSAP Survey System Enhancement	Form	New	Available
Form 0920-1154 Screener Telephone Interview	Form and Instruction	New	Available
Form 0920-1154 Screener Focus Group	Form and Instruction	New	Available
Form 0920-1154 Interview Protocol - Non-Users	Form and Instruction	New	Available
Form 0920-1154 Interview Protocol - Users	Form and Instruction	New	Available
Form 0920-1154 Focus Group Protocol - Non-Users	Form and Instruction	New	Available
Form 0920-1154 Focus Group Protocol - Users	Form and Instruction	New	Available
Form 0920-1154 Written Questionnaire Focus Group	Form and Instruction	New	Available
Prescriber Assessment	Form	New	Available
Form 0920-1154 Focus Group Moderator Guide	Form and Instruction	New	Available
Form 0920-1154 Online Screener	Form	New	Available
Form 0920-1154 ACOG Evaluation of Local Health Department Initiative	Form and Instruction	New	Available
Form 0920-1154 Focus Group Recruitment Screen	Form and Instruction	New	Available
Form 0920-1154 ACOG Zika Virus Survey	Form	New	Available
Spanish Language Focus Group Discussion Guide	Form and Instruction	New	Available
English Language Focus Group Discussion Guide	Form and Instruction	New	Available
Spanish Language Screening Instrument	Form and Instruction	New	Available
English Language Screening Instrument	Form and Instruction	New	Available
LCP Staff/Coach Interview Guide	Form and Instruction	New	Available
Enrollment Materials and Referral Tracking Form	Form and Instruction	New	Available
Post-Session Survey	Form and Instruction	New	Available
Pre-Session Survey	Form and Instruction	New	Available
Form 0920-1154 Disability and Halth Data System Evaulation Survey	Form and Instruction	New	Available
Form 0920-1154 IN-DEPTH INTERVIEWS WITH WOMEN AFFECTED BY THE ZIKA VIRUS - INTERVIEW GUIDE	Form and Instruction	New	Available
Survey of Experiences with and Attitudes towards Zika Virus	Form	New	Available
Form 0920-1154 Survey - Website User	Form and Instruction	New	Available
Form 0920-1154 Pop-Up Invitation to Survey - Website User	Form and Instruction	New	Available
Form 0920-1154 Survey - Healthcare Professional	Form and Instruction	New	Available
Form 0920-1154 Reminder Invitation Email to access Survey - Health Care Professional	Form and Instruction	New	Available
Form 0920-1154 Invitation Email to access Survey - Health Care Professional	Form and Instruction	New	Available
Focus Group - Vignette	Form and Instruction	New	Available
Feedback Questionnaire	Form	New	Available
Hospital Antibiotic Stewardship Core Element Assessment	Form	New	Available
Screener	Form	New	Available
Interview Guide - Public Health Officials	Form and Instruction	New	Available
Survey of Parents of Adolescents with Congenital Heart Defects	Form	New	Available
Screener	Form and Instruction	New	Available
Consumer Interview - CE - CD	Form	New	Available
Consumer Interview - SE - SD	Form	New	Available
HCP Antibiotic Use Interview	Form	New	Available
Consumer Screener - CD - CE	Form	New	Available
Consumer Screener - SD-SE	Form	New	Available
HCP Antibiotic Use Screener	Form	New	Available
HCP Interview Sepsis	Form	New	Available
Consumer Interview Sepsis	Form	New	Available
HCP Sepsis Screener - Gen med ward	Form	New	Available
HCP Sepsis Screener - PCP	Form	New	Available
HCP Sepsis Screener - NP or PA	Form	New	Available
HCP Sepsis Screener - ED triage nurse	Form	New	Available
Sepsis Consumer Screener - AA men	Form	New	Available
Sepsis Consumer Screener - healthy adults 65+	Form	New	Available
Sepsis Consumer Screener - mothers	Form	New	Available
GenICRequestTemplate.docx	Supplementary Document	Uploaded 2016-10-20	Available
60dayFRN.pdf	Supplementary Document	Uploaded 2016-10-20	Available
AuthLegislation.doc	Supplementary Document	Uploaded 2016-10-20	Available
SSB.docx	Supporting Statement B	Uploaded 2016-10-20	Available
ATSDR Formative Research and Tool Development Generic_OMB.doc	Supporting Statement A	Uploaded 2017-01-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
239014	Determination of Attitudes Regarding Noise in Construction	Form and Instruction	New	Construction Workers Focus Groups (SPANISH)
239014	Determination of Attitudes Regarding Noise in Construction	Form and Instruction	New	Construction Workers Focus Groups (ENGLISH)
239014	Determination of Attitudes Regarding Noise in Construction	Form and Instruction	New	Construction Supervisor/Foreman Focus Group
239014	Determination of Attitudes Regarding Noise in Construction	Form and Instruction	New	Construction Industry Executive/Decision-Maker In-Depth Interviews
238970	Participatory Mapping to Identify and Support At-Risk Populations in Emergency Preparedness – Phase 3	Form and Instruction	New	Survey Disaster Planners
238392	Formative Research to Inform an Intervention to Improve Early Detection and Surveillance of Pneumoconiosis in US Coal Miners	Form	New	Interview sign-up
238392	Formative Research to Inform an Intervention to Improve Early Detection and Surveillance of Pneumoconiosis in US Coal Miners	Form	New	Focus group demographic survey
238392	Formative Research to Inform an Intervention to Improve Early Detection and Surveillance of Pneumoconiosis in US Coal Miners	Form	New	Interview demographic survey
238392	Formative Research to Inform an Intervention to Improve Early Detection and Surveillance of Pneumoconiosis in US Coal Miners	Other-Interview guide	New
238224	Formative Assessment of the Information Needs to Prevent Skin Cancer Among Spanish speaking Outdoor Workers	Other-Focus Group Guide	New
237867	2019 Updated B Reader Certification Examination	Other-WORD	New
237140	Formative Research to Identify Common and Unique Barriers to the Exchange of Hospitalization and ED Data	Form	New	Survey prenotice
237140	Formative Research to Identify Common and Unique Barriers to the Exchange of Hospitalization and ED Data	Form	New	Survey - word
237140	Formative Research to Identify Common and Unique Barriers to the Exchange of Hospitalization and ED Data	Form	New	Survey
236579	Formative Assessment of the Information Needs to Prevent Work-related Musculoskeletal Disorders and Falls among Aging Retail Workers	Other-Focus group guide	New
236556	Reaching Minority Men Where They Are – Formative Research to Build Capacity for Enrollment in Diabetes Prevention and Management Programs	Form and Instruction	New	Survey (content)
236556	Reaching Minority Men Where They Are – Formative Research to Build Capacity for Enrollment in Diabetes Prevention and Management Programs	Form and Instruction	New	Initial Screen Shot of the Web-based Survey (with OMB control information)
236556	Reaching Minority Men Where They Are – Formative Research to Build Capacity for Enrollment in Diabetes Prevention and Management Programs	Form and Instruction	New	Screener
236556	Reaching Minority Men Where They Are – Formative Research to Build Capacity for Enrollment in Diabetes Prevention and Management Programs	Form and Instruction	New	Focus Group Guide: Minority Men Diagnosed with Type 2 Diabetes
236556	Reaching Minority Men Where They Are – Formative Research to Build Capacity for Enrollment in Diabetes Prevention and Management Programs	Form and Instruction	New	Focus Group Guide: Minority Men at Risk for Type 2 Diabetes
236243	Formative Research to Develop an Open Data Standard for Reporting Environmental Health Data	Form and Instruction	New	Key Informant Interview Plan
235993	Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy	Form	New	Provider Screener and Online Survey
235993	Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy	Form and Instruction	New	Consent Form Women In-Depth Interview
235993	Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy	Form and Instruction	New	Consent Form Provider In-Depth Interview
235993	Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy	Form and Instruction	New	Consent Form Provider (Online Survey)
235993	Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy	Other-Screenshots	New
235328	Focus Groups of US Adults KAP of Foodborne Disease Outbreaks and Illness Prevention	Form and Instruction	New	Recruitment Follow-up Contact
235328	Focus Groups of US Adults KAP of Foodborne Disease Outbreaks and Illness Prevention	Form and Instruction	New	Recruitment Screener
235328	Focus Groups of US Adults KAP of Foodborne Disease Outbreaks and Illness Prevention	Other-Moderator Guide	New
235305	BRFSS Feasibility Experiment for State-specific Module Data Collection in Cell Phone Samples	Form and Instruction	New	Questionnaire Content
234224	Clinician Preferences for CDC Clinical Guidelines	Other-WORD	New
233456	Formative Research with Clinicians for the Development of Quantitative Metrics to Improve Antibiotic Prescribing Behavior in the Outpatient Setting	Other-WORD	New
232735	Federal Select Agent Program eFSAP Feedback Survey	Form	New	FSAP User Experience Survey
232735	Federal Select Agent Program eFSAP Feedback Survey	Form	New	FSAP Survey System Enhancement
232408	Participatory Mapping to Identy and Support at Risk Population in Emergency Preparedness -- Phase 2	Other-WORD	New
231946	Older Adult Mobility Ride Share (OAMRS)	Form and Instruction	New	Screener Telephone Interview
231946	Older Adult Mobility Ride Share (OAMRS)	Form and Instruction	New	Screener Focus Group
231946	Older Adult Mobility Ride Share (OAMRS)	Form and Instruction	New	Interview Protocol - Non-Users
231946	Older Adult Mobility Ride Share (OAMRS)	Form and Instruction	New	Interview Protocol - Users
231946	Older Adult Mobility Ride Share (OAMRS)	Form and Instruction	New	Focus Group Protocol - Non-Users
231946	Older Adult Mobility Ride Share (OAMRS)	Form and Instruction	New	Focus Group Protocol - Users
231946	Older Adult Mobility Ride Share (OAMRS)	Form and Instruction	New	Written Questionnaire Focus Group
231812	Core Elements of Antimicrobial Stewardship in Nursing Homes	Form	New	Prescriber Assessment
231343	Behavioral Determinants of Community Hand Hygiene Behavior: A Formative Qualitative Evaluation	Form and Instruction	New	Focus Group Moderator Guide
231343	Behavioral Determinants of Community Hand Hygiene Behavior: A Formative Qualitative Evaluation	Form	New	Online Screener
231333	FORMATIVE RESEARCH TO DEVELOP ZIKA TOOLS FOR HEALTHCARE PROVIDERS	Form and Instruction	New	ACOG Evaluation of Local Health Department Initiative
231333	FORMATIVE RESEARCH TO DEVELOP ZIKA TOOLS FOR HEALTHCARE PROVIDERS	Form and Instruction	New	Focus Group Recruitment Screen
231333	FORMATIVE RESEARCH TO DEVELOP ZIKA TOOLS FOR HEALTHCARE PROVIDERS	Form	New	ACOG Zika Virus Survey
231333	FORMATIVE RESEARCH TO DEVELOP ZIKA TOOLS FOR HEALTHCARE PROVIDERS	Other-Focus Group Discussion Guide - OB-GYN/PEDS/MIDWIVES/NPs	New
231332	CDC's Inside Knowledge Campaign: 2018 Focus Group Research and Testing with the General Public and Hispanic Audiences	Form and Instruction	New	Spanish Language Focus Group Discussion Guide
231332	CDC's Inside Knowledge Campaign: 2018 Focus Group Research and Testing with the General Public and Hispanic Audiences	Form and Instruction	New	English Language Focus Group Discussion Guide
231332	CDC's Inside Knowledge Campaign: 2018 Focus Group Research and Testing with the General Public and Hispanic Audiences	Form and Instruction	New	Spanish Language Screening Instrument
231332	CDC's Inside Knowledge Campaign: 2018 Focus Group Research and Testing with the General Public and Hispanic Audiences	Form and Instruction	New	English Language Screening Instrument
231069	Increase Enrollment in the CDC-Recognized Lifestyle Change Program (LCP)	Form and Instruction	New	LCP Staff/Coach Interview Guide
231069	Increase Enrollment in the CDC-Recognized Lifestyle Change Program (LCP)	Form and Instruction	New	Enrollment Materials and Referral Tracking Form
231069	Increase Enrollment in the CDC-Recognized Lifestyle Change Program (LCP)	Form and Instruction	New	Post-Session Survey
231069	Increase Enrollment in the CDC-Recognized Lifestyle Change Program (LCP)	Form and Instruction	New	Pre-Session Survey
230837	Disability and Health Data System Evaluaton Survey	Form and Instruction	New	Disability and Halth Data System Evaulation Survey
230823	Zika Family Survey: In-Depth Interviews with Women Affected by Zika Virus	Form and Instruction	New	IN-DEPTH INTERVIEWS WITH WOMEN AFFECTED BY THE ZIKA VIRUS - INTERVIEW GUIDE
230823	Zika Family Survey: In-Depth Interviews with Women Affected by Zika Virus	Instruction	New
230045	Formative Research to Assess Pediatric Healthcare Providers Knowledge, Attitudes and Practices around Zika Virus	Form	New	Survey of Experiences with and Attitudes towards Zika Virus
229528	Assessment of the Zika Care Connect Program	Form and Instruction	New	Survey - Website User
229528	Assessment of the Zika Care Connect Program	Form and Instruction	New	Pop-Up Invitation to Survey - Website User
229528	Assessment of the Zika Care Connect Program	Form and Instruction	New	Survey - Healthcare Professional
229528	Assessment of the Zika Care Connect Program	Form and Instruction	New	Reminder Invitation Email to access Survey - Health Care Professional
229528	Assessment of the Zika Care Connect Program	Form and Instruction	New	Invitation Email to access Survey - Health Care Professional
228512	Persuasive Communication about Risks from and Responses to Zika: FOCUS GROUPS	Form and Instruction	New	Focus Group - Vignette
227942	BRFSS Preliminary Experiment for Sample and Mode	Other-WORD	New
227437	Antibiotic Stewardship in Hospitals Assessment	Form	New	Feedback Questionnaire
227437	Antibiotic Stewardship in Hospitals Assessment	Form	New	Hospital Antibiotic Stewardship Core Element Assessment
226670	Formative Evaluation for Shigellosis Sexual Health Materials for Men who have Sex with Men	Form	New	Screener
226670	Formative Evaluation for Shigellosis Sexual Health Materials for Men who have Sex with Men	Other-Moderator's Guide	New
226552	Participatory Mapping to Identify and Support at-Risk Populations in Emergency Preparedness	Other-Interview Guide	New
226486	Persuasive Communication about Risks from and Responses to Zika – State, Local and Tribal Government Interviews	Form and Instruction	New	Interview Guide - Public Health Officials
226379	Formative Assessment of Barriers to Transition from Adolescent to Adult for Individuals with Congenital Heart Defects	Form	New	Survey of Parents of Adolescents with Congenital Heart Defects
226269	Reframing How We Talk About Alcohol	Form and Instruction	New	Screener
226269	Reframing How We Talk About Alcohol	Other-Moderator Guide	New
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	Consumer Interview - CE - CD
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	Consumer Interview - SE - SD
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	HCP Antibiotic Use Interview
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	Consumer Screener - CD - CE
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	Consumer Screener - SD-SE
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	HCP Antibiotic Use Screener
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	HCP Interview Sepsis
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	Consumer Interview Sepsis
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	HCP Sepsis Screener - Gen med ward
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	HCP Sepsis Screener - PCP
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	HCP Sepsis Screener - NP or PA
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	HCP Sepsis Screener - ED triage nurse
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	Sepsis Consumer Screener - AA men
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	Sepsis Consumer Screener - healthy adults 65+
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Form	New	Sepsis Consumer Screener - mothers
225603	Formative Research for Sepsis and Antibiotic Use Campaigns	Other-Focus Group Guide	New

ICR Details

OMB Control No: 0920-1154	ICR Reference No: 201610-0920-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 16AVC
Title: CDC/ATSDR Formative Research and Tool Development
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/19/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/26/2016
Terms of Clearance: OMB approves this umbrella generic, and has informed CDC/ATSDR that each individual study should be submitted into ROCIS an a genIC that includes full supporting statement Part A and an accompanying Supporting Statement Part B if any statistical methods are employed for sampling or analyses of data. A complete justification for any incentives offered to respondents will also accompany all substudies submitted under this Generic. Outcomes collected under this generic pathway are intended for internal ATSDR use only and will not be generalized beyond the scope of each study or to broader populations.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved
Responses	60,000	0	0
Time Burden (Hours)	56,250	0	0
Cost Burden (Dollars)	1,125,000	0	0

---

Abstract: CDC proposes a new generic clearance to conduct formative research for developing new tools and methodologies to support agency research, surveillance, and program evaluation activities, and the development and assessment of multi-use tools.

---

Authorizing Statute(s): US Code: 42 USC 241 Name of Law: PHSA
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 46680	07/18/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 73112	10/24/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 35

table that charts list of burden

IC Title	Form No.	Form Name
2019 Updated B Reader Certification Examination
Antibiotic Stewardship in Hospitals Assessment	none, none	Hospital Antibiotic Stewardship Core Element Assessment ,   Feedback Questionnaire
Assessment of the Zika Care Connect Program	0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154	Invitation Email to access Survey - Health Care Professional ,   Reminder Invitation Email to access Survey - Health Care Professional ,   Survey - Healthcare Professional ,   Pop-Up Invitation to Survey - Website User ,   Survey - Website User
BRFSS Feasibility Experiment for State-specific Module Data Collection in Cell Phone Samples	0920-1154	Questionnaire Content
BRFSS Preliminary Experiment for Sample and Mode
Behavioral Determinants of Community Hand Hygiene Behavior: A Formative Qualitative Evaluation	0920-1154, 0920-1154	Online Screener ,   Focus Group Moderator Guide
CDC's Inside Knowledge Campaign: 2018 Focus Group Research and Testing with the General Public and Hispanic Audiences	n/a, n/a, n/a, n/a	English Language Screening Instrument ,   Spanish Language Screening Instrument ,   English Language Focus Group Discussion Guide ,   Spanish Language Focus Group Discussion Guide
Clinician Preferences for CDC Clinical Guidelines
Core Elements of Antimicrobial Stewardship in Nursing Homes	none	Prescriber Assessment
Determination of Attitudes Regarding Noise in Construction	0920-1154, 0920-1154, 0920-1154, 0920-1154	Construction Industry Executive/Decision-Maker In-Depth Interviews ,   Construction Supervisor/Foreman Focus Group ,   Construction Workers Focus Groups (ENGLISH) ,   Construction Workers Focus Groups (SPANISH)
Disability and Health Data System Evaluaton Survey	0920-1154	Disability and Halth Data System Evaulation Survey
Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy	0920-1154, 0920-1154, 0920-1154, 0920-1154	Consent Form Provider (Online Survey) ,   Consent Form Provider In-Depth Interview ,   Consent Form Women In-Depth Interview ,   Provider Screener and Online Survey
FORMATIVE RESEARCH TO DEVELOP ZIKA TOOLS FOR HEALTHCARE PROVIDERS	0920-1154, 0920-1154, 0920-1154	ACOG Zika Virus Survey ,   Focus Group Recruitment Screen ,   ACOG Evaluation of Local Health Department Initiative
Federal Select Agent Program eFSAP Feedback Survey	0920-1154, 0920-1154	FSAP Survey System Enhancement ,   FSAP User Experience Survey
Focus Groups of US Adults KAP of Foodborne Disease Outbreaks and Illness Prevention	none, none	Recruitment Screener ,   Recruitment Follow-up Contact
Formative Assessment of Barriers to Transition from Adolescent to Adult for Individuals with Congenital Heart Defects	none	Survey of Parents of Adolescents with Congenital Heart Defects
Formative Assessment of the Information Needs to Prevent Skin Cancer Among Spanish speaking Outdoor Workers
Formative Assessment of the Information Needs to Prevent Work-related Musculoskeletal Disorders and Falls among Aging Retail Workers
Formative Evaluation for Shigellosis Sexual Health Materials for Men who have Sex with Men	none	Screener
Formative Research for Sepsis and Antibiotic Use Campaigns	none, none, none, none, none, none, none, none, none, none, none, none, none, none, none	Sepsis Consumer Screener - mothers ,   Sepsis Consumer Screener - healthy adults 65+ ,   Sepsis Consumer Screener - AA men ,   HCP Sepsis Screener - ED triage nurse ,   HCP Sepsis Screener - NP or PA ,   HCP Sepsis Screener - PCP ,   HCP Sepsis Screener - Gen med ward ,   Consumer Interview Sepsis ,   HCP Interview Sepsis ,   HCP Antibiotic Use Screener ,   Consumer Screener - SD-SE ,   Consumer Screener - CD - CE ,   HCP Antibiotic Use Interview ,   Consumer Interview - SE - SD ,   Consumer Interview - CE - CD
Formative Research to Assess Pediatric Healthcare Providers Knowledge, Attitudes and Practices around Zika Virus	none	Survey of Experiences with and Attitudes towards Zika Virus
Formative Research to Develop an Open Data Standard for Reporting Environmental Health Data	0920-1154	Key Informant Interview Plan
Formative Research to Identify Common and Unique Barriers to the Exchange of Hospitalization and ED Data	none, none, none	Survey ,   Survey - word ,   Survey prenotice
Formative Research to Inform an Intervention to Improve Early Detection and Surveillance of Pneumoconiosis in US Coal Miners	none, none, none	Interview demographic survey ,   Focus group demographic survey ,   Interview sign-up
Formative Research with Clinicians for the Development of Quantitative Metrics to Improve Antibiotic Prescribing Behavior in the Outpatient Setting
Increase Enrollment in the CDC-Recognized Lifestyle Change Program (LCP)	NA, NA, NA, NA	Pre-Session Survey ,   Post-Session Survey ,   Enrollment Materials and Referral Tracking Form ,   LCP Staff/Coach Interview Guide
Older Adult Mobility Ride Share (OAMRS)	0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154	Written Questionnaire Focus Group ,   Focus Group Protocol - Users ,   Focus Group Protocol - Non-Users ,   Interview Protocol - Users ,   Interview Protocol - Non-Users ,   Screener Focus Group ,   Screener Telephone Interview
Participatory Mapping to Identify and Support At-Risk Populations in Emergency Preparedness – Phase 3	0920-1154	Survey Disaster Planners
Participatory Mapping to Identify and Support at-Risk Populations in Emergency Preparedness
Participatory Mapping to Identy and Support at Risk Population in Emergency Preparedness -- Phase 2
Persuasive Communication about Risks from and Responses to Zika – State, Local and Tribal Government Interviews	NA	Interview Guide - Public Health Officials
Persuasive Communication about Risks from and Responses to Zika: FOCUS GROUPS	NA	Focus Group - Vignette
Reaching Minority Men Where They Are – Formative Research to Build Capacity for Enrollment in Diabetes Prevention and Management Programs	n/a, n/a, n/a, n/a, n/a	Focus Group Guide: Minority Men at Risk for Type 2 Diabetes ,   Focus Group Guide: Minority Men Diagnosed with Type 2 Diabetes ,   Screener ,   Initial Screen Shot of the Web-based Survey (with OMB control information) ,   Survey (content)
Reframing How We Talk About Alcohol	none	Screener
Zika Family Survey: In-Depth Interviews with Women Affected by Zika Virus	0920-1154	IN-DEPTH INTERVIEWS WITH WOMEN AFFECTED BY THE ZIKA VIRUS - INTERVIEW GUIDE

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	60,000	0	0	60,000	0	0
Annual Time Burden (Hours)	56,250	0	0	56,250	0	0
Annual Cost Burden (Dollars)	1,125,000	0	0	1,125,000	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new generic ICR.

---

Annual Cost to Federal Government: $474,091

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/26/2016

---