Request for genIC Approval

Request for genIC Approval

CDC/ATSDR Formative Research and Tool Development

0920-1154

CIO: NCCDPHP

PROJECT TITLE: Generic ICR for BRFSS Sampling Preliminary Experiment for the National Center for Chronic Disease Prevention and Health Promotion

PURPOSE AND USE OF COLLECTION:

This proposal requests clearance to conduct test of the efficiency of modes of data collection for survey methodologies under consideration for public health surveillance and programmatic efforts overseen by the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC). The purpose of the sampling preliminary experiments will be to assess the cost effectiveness and data quality from sequential modes of data collection based on telephone and address-based methodologies.

DESCRIPTION OF RESPONDENTS:

Adult residents (≥ 18 years of age).

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.

Name: ______Carol Pierannunzi_____________________________________

To assist review, please answer the following questions:

Personally Identifiable Information:

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

Samples will include phone numbers and addresses. Sample files will not be included in data files created by the data collection. Sample files will be destroyed after completion of the pilot.

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [ x ] 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

Type of Respondent	Form Name	Number of Respondents	Number of Responses per Respondent	Average Burden per Response (in hours)	Total Burden (in hrs.)
Telephone Sample
General U.S. Adult Population	Address Matched Web-based questionnaire	300 x 5 states =1,500	1	15/60	375
	Address-Matched Mailed Questionnaire	300 x 5 states =1,500	1	15/60	375
	Address Matched Telephone Interviewer	300 x 5 states =1,500	1	15/60	375
	Not Address- matched telephone interview	300 x 5 states =1,500	1	15/60	375
Address-Based Sample
General U.S. Adult Population	Phone Matched Web-based questionnaire	300 x 5 states =1,500	1	15/60	375
	Phone Matched Mailed Questionnaire	300 x 5 states =1,500	1	15/60	375
	Phone Matched Telephone Interviewer	300 x 5 states =1,500	1	15/60	375
	Not Phone matched Web-based interview	300 x 5 states =1,500	1	15/60	375
	Not Phone Matched Mailed Survey	300 x 5 states =1,500	1	15/60	375
Total		13,500			3,375

FEDERAL COST: The estimated annual cost to the Federal government is __$250,000_

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 ] Yes [ ] 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?

Telephone samples are taken from listings of all working phone numbers in each state. Numbers to be included in the sample are selected using Random Digit Dialing (RDD).

Address samples are taken from the list of households maintained by the US Postal Service. Individual addresses are selected at random.

Marketing Systems Group (MSG) will create the random sample from current Telecordia phone listing and USPS address lists.

Administration of the Instrument

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

[ x ] Web-based or other forms of Social Media

[ x ] Telephone

[ ] In-person

[ x ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [x ] Yes [ ] No

Interviewers will be used for the portion of the sample who are contacted by phone.

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

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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