0920-1154 GenIC Request Template - OPHPR

Request for genIC Approval
CDC/ATSDR Formative Research and Tool Development
0920-1154
CIO: OPHPR
PROJECT TITLE: Persuasive Communication about Risks from and Response to Zika – State,
Local and Tribal Government Interviews
PURPOSE AND USE OF COLLECTION:
The goal of this generic information collection request is to conduct in-depth, semi-structured
interviews (~45 minutes) with approximately 30 state, local and tribal government public health
practitioners, mosquito control officers, public health policymakers, and public health information
officers to develop a detailed understanding of both the standard and innovative communication
efforts ongoing in the response to Zika. This is part of a larger two-year study using a novel,
multifaceted approach to investigate the sending and receiving aspects of communication and the
relationship of the two to understand and provide recommendations for how public health
communication practices can be strengthened to improve public understanding of, acceptance of,
and response to messages during this and future infectious disease outbreaks.
DESCRIPTION OF RESPONDENTS: 30 state, local and tribal government public health
practitioners, mosquito control officers, public health policymakers, and public health information
officers
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. Information gathered will not be used to substantially inform influential policy decisions.
5. The study is not intended to produce results that can be generalized beyond its scope.
Digitally signed by Laura Pechta -S (Affiliate)
DN: c=US, o=U.S. Government, ou=HHS, ou=CDC, ou=People,
0.9.2342.19200300.100.1.1=1001482095, cn=Laura Pechta -S (Affiliate)
Date: 2017.04.13 09:09:57 -04'00'

Laura Pechta -S (Affiliate)
Name: ___________________________________

To assist review, please answer the following questions:
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:
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Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to
participants? [ ] Yes [ X] No
BURDEN HOURS

Category of Respondent

Form Name

No. of
Respondents

Participation
Time (minutes)

Burden in Hours

State, local and tribal
government public health
officials

Attachment F –

30

45

23

Interview Guide Public
Health Officials

Totals

30

23

FEDERAL COST: The estimated annual cost to the Federal government is _$850.31______

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?
Respondent contact information for the interview portion of the research will be gathered from
existing databases of public health stakeholders maintained at CHS. These stakeholders have
actively participated in previous interview-based research performed by CHS. Additional names and
contact information of public officials will be gained from internet searches of publically available
documents and recommendations from other interviewees (snowball sampling method).
Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[ ] Web-based or other forms of Social Media
[ X ] Telephone
[ ] In-person
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[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ X ] Yes [ ] No

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

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Instructions for completing genIC Request for Approval for
CDC/ATSDR Formative Research and Tool Development
TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is requested.
PURPOSE and USE: Provide a brief description of the purpose of this collection 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: Briefly describe the targeted group/groups for this collection.
CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will
be returned as improperly submitted or it will be disapproved.
Personally Identifiable Information: Provide answers to the questions.
Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a
justification for the amount.

BURDEN HOURS:
Category of Respondents: Identify who you expect the respondents to be in terms of the following
categories: (1) Individuals or Households; (2) Private Sector; (3) State, local, or tribal governments;
or (4) Federal Government. Only one type of respondent can be selected.
Form: Provide the title of the information collection form.
No. of Respondents: Provide an estimate of the Number of respondents.
Participation Time: Provide an estimate of the amount of time required for a respondent to
participate (e.g. fill out a survey or participate in a focus group).
Burden in Minutes: Multiply the Number of responses and the participation time and divide by 60.
FEDERAL COST: Estimate the annual cost to the Federal government for this collection.
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. Please provide a description of how you plan to
identify your potential group of respondents and how you will select them. If the answer is yes, to
the first question, you may provide the sampling plan in an attachment.
Administration of the Instrument: Identify how the information will be collected. More than one
box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators
(e.g., for focus groups) used.

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