Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-1009 Course Evaluation Questions	Form and Instruction	New	Available
Form 0920-1009 Feedback Survey	Form and Instruction	New	Available
Form 0920-1009 VetoViolence Evaluation- Spring 2019	Form and Instruction	New	Available
Screener	Form	New	Available
Form 0920-1009 Course Specific Evaluation Questions	Form and Instruction	New	Available
Form 0920-1009 17BAV Attachment 3. Survey Screen Shots	Form and Instruction	New	Available
Form 0920- 17AV Attachment 2 Survey	Form and Instruction	New	Available
Form 0920-17AQJ Att 1_Webinar Feedback Form_May_2017	Form and Instruction	New	Available
Att D. Instrument_GenIC_RequestTemplate.docx	Supplementary Document	Uploaded 2016-12-12	Available
SSB_ OMB-1009 - Servie Delivery_NCIPC.docx	Supporting Statement B	Uploaded 2016-12-12	Available
SSA_0920-1009_021317_v2.docx	Supporting Statement A	Uploaded 2017-02-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
237904	Preventing Adverse Childhood Experiences Pediatric Medical Provider Module Online Course	Form and Instruction	New	Course Evaluation Questions
237691	Recipient Meeting Participant's Feedback - Division of Violence Prevention	Form and Instruction	New	Feedback Survey
235581	VETO Volence Tools and Training Customer Satisfaction	Form and Instruction	New	VetoViolence Evaluation- Spring 2019
235581	VETO Volence Tools and Training Customer Satisfaction	Other-ord	New
234744	WISQARS Data Visualization Usability Testing Customer Feedback	Form	New	Screener
234744	WISQARS Data Visualization Usability Testing Customer Feedback	Other-Discussion Guide	New
230187	Stopping Elderly Accidents, Deaths, and Injuries (STEADI) in a Hospital Discharge Setting	Other-WORD	New
230144	Bullying Prevention Online Course –Evaluation Questions - Course Specific	Form and Instruction	New	Course Specific Evaluation Questions
228321	Customer Satisfaction and Usability of the Technical Packages for Violence Prevention	Other-WORD	New
228213	Website Usability Testing Customer Feedback. DVP	Form and Instruction	New	Attachment 3. Survey Screen Shots
228213	Website Usability Testing Customer Feedback. DVP	Form and Instruction	New	Attachment 2 Survey
227884	Customer Satisfaction and Usability of Technical Packages for Violence Prevention	Other-WORD	New
227244	Division of Violence Prevention web-based Technical assistance Participant's Feedback	Form and Instruction	New	Att 1_Webinar Feedback Form_May_2017

ICR Details

OMB Control No: 0920-1009	ICR Reference No: 201612-0920-007
Status: Historical Active	Previous ICR Reference No: 201405-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No: 21359
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/28/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/12/2016
Terms of Clearance: Previous Terms continue: OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request. No payment or other form of remuneration will be provided to respondents for GenICs submitted under this generic. Focus groups and cognitive laboratory studies are the exceptions and will contain a comprehensive justification for why the incentive is necessary within the submitted sub-study.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved	03/31/2017
Responses	61,920	0	228,000
Time Burden (Hours)	18,315	0	104,250
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information is necessary to enable the Agency to garner customer and stateholder feedback in an efficient, timely manner, in accordance with our commitment to improving service elivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the Agency's programs. The responsible unit is the National Center for Injury Prevention and Control within the Centers for Disease Control and Prevention.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 24432	04/30/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 89465	12/12/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
Bullying Prevention Online Course –Evaluation Questions - Course Specific	0920-1009	Course Specific Evaluation Questions
Customer Satisfaction and Usability of Technical Packages for Violence Prevention
Customer Satisfaction and Usability of the Technical Packages for Violence Prevention
Division of Violence Prevention web-based Technical assistance Participant's Feedback	0920-17AQJ	Att 1_Webinar Feedback Form_May_2017
Preventing Adverse Childhood Experiences Pediatric Medical Provider Module Online Course	0920-1009	Course Evaluation Questions
Recipient Meeting Participant's Feedback - Division of Violence Prevention	0920-1009	Feedback Survey
Stopping Elderly Accidents, Deaths, and Injuries (STEADI) in a Hospital Discharge Setting
VETO Volence Tools and Training Customer Satisfaction	0920-1009	VetoViolence Evaluation- Spring 2019
WISQARS Data Visualization Usability Testing Customer Feedback	none	Screener
Website Usability Testing Customer Feedback. DVP	0920- 17AV, 0920-1009 17BAV	Attachment 2 Survey ,   Attachment 3. Survey Screen Shots

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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	61,920	228,000	0	-166,080	0	0
Annual Time Burden (Hours)	18,315	104,250	0	-85,935	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Based on the number of burden hours actually used during the initial approval period and the number of respondents involved in this and other expiring collections, we are requesting a decrease in the number of respondents and burden hours.

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Annual Cost to Federal Government: $55,000

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

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Common Form ICR:  No

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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: 12/12/2016

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