Service Delivery Fasttrack Template

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 0920-1071)
TITLE OF INFORMATION COLLECTION:
Acceptability Survey of ARI Campaign for University of Utah Pediatric Clinic Champions
&
Acceptability Survey of ARI Campaign for University of Utah Pediatric Providers
PURPOSE:
From January 2018 through July 2019 University of Utah pediatric providers participated in an
operational intervention designed to improve antibiotic prescribing for acute upper respiratory
tract infections (ARI) such as acute sinusitis, acute otitis media, and non-specific upper
respiratory tract infections. The study (ARI Campaign) emphasized the use of a dashboard report
(audit-feedback) and academic detailing.
 The dashboard report included a summary of individual clinic providers’ distribution of
ARI diagnoses and antibiotic prescribing patterns for treatment of ARI.
 Academic detailing visits consisted of personalized one-on-one or small group
educational sessions from a Pediatric Infectious Diseases specialist to discuss antibiotic
prescribing for ARIs.
In addition, patient education materials were provided to clinics at the start of the intervention.
This survey aims to gauge opinions on the ARI Campaign elements and elicit suggestions for
improvement through the completion of an online survey administered through the University of
Utah’s REDCap Survey Tool. Survey links will be sent in an e-mail from designated research
personnel with additional information about the study. Participants will be contacted no more
than three times for completion of this survey and may be potentially contacted by phone.
Responses may be tracked via an e-mail link, to facilitate administration of the survey and send
reminders to remaining potential participants. The intervention elements evaluated in the study
are promising approaches to improving antibiotic prescribing and health outcomes; however,
there is scant information available on how best to implement these programs and select
elements of the intervention are resource intensive to deliver. The survey purpose is to obtain
opinions of individuals who were asked to deliver and receive the intervention in order to gain
insight into which intervention elements were of value to participants and what resources are
needed to sustain the interventional approach. Ultimately, responses will be used to refine
delivery of the ARI Campaign and gauge clinic champion and participating providers
acceptability of the interventional approach.
DESCRIPTION OF RESPONDENTS:
The targeted population for the pediatric provider clinic champion survey includes all University
of Utah personnel who facilitated one or more components of the ARI Campaign during the
Option Period 1 portion of the operational intervention at the following University of Utah
affiliated clinics: Greenwood Health Center; Redwood Health Center; South Jordan Health
Center; South Main Clinic; University Hospitals and Clinics; Westridge Health Center. It is
anticipated that no more than 6 pediatric champions will be sent the survey link.
The targeted population for the provider survey includes all providers who received one auditfeedback report during the Option Period 1 portion of the operational intervention at the
following University of Utah affiliated clinics: Greenwood Health Center; Redwood Health
Center; South Jordan Health Center; South Main Clinic; University Hospitals and Clinics;
1

Westridge Health Center. It is anticipated that up to 175 providers will be sent the survey link,
and no more than 200 will be sent the survey link.
We plan to record specific provider demographics i.e., age and sex, as these are potentially
important predictors of inappropriate treatment of ARIs with antibiotics. While the quality
improvement intervention was not specifically targeted to providers based on age or sex, we
believe that provider perception of intervention components may vary by age and/or sex. For
example, female providers may have a more favorable impression of academic detailing whereas
male providers may be more receptive to data delivered in feedback reports. Therefore, we
believe that the age and sex questions should be included in the surveys.
TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[X] Customer Satisfaction Survey
[ ] Small Discussion Group
[ ] Other:  

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. The results are not intended to be disseminated to the public.
5. Information gathered will not be used for the purpose of substantially informing influential
policy decisions.
6. 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.

Name:_____________________________________
To assist review, please provide answers to the following question:
Personal Identifiable Information:
1. Is personal identifiable information (PII) collected? [X] Yes [ ] No
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

2

Category of Respondent

No. of
Respondents
6
200
206

Non-federal Pediatric Provider (Champions)
Non-federal Pediatric Provider
Totals

Participation
Time
0.5 Hour
0.5 Hour

Burden
3 Hours
100 Hours
103 Hours

FEDERAL COST: The estimated annual cost to the Federal government is $25,442*
*The annual cost listed will cover 0.25 FTE effort of a Data Analyst to analyze the data gathered
from the surveys.
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?
Potential participants for the clinic champion survey have been facilitating a quality
improvement program from September 2018 to present. Study investigators have been working
with clinic champions who have facilitated intervention delivery of the quality improvement
program to providers throughout the entire study. Site investigators will send participant lists to
study personnel tasked with facilitating and administering the survey within the University of
Utah. Personnel tasked with administering the survey will send an e-mail to identified facilitators
which includes the survey link.
Potential participants for the provider survey have been participating in a quality improvement
program from September 2018 to present. As part of the program, participants receive an emailed link to personalized prescribing data. Implementation personnel have access and records
of which providers have received a report. These personnel will send participant lists to study
personnel tasked with facilitating and administering the survey within the University of Utah.
Personnel tasked with administering the survey will send an e-mail to identified providers which
includes the survey link. 
Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[X] Web-based or other forms of Social Media
[ ] Telephone
[ ] In-person
[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ ] Yes [X] No
Please make sure that all instruments, instructions, and scripts are submitted with the
request.

3

Instructions for completing Request for Approval under the “Generic
Clearance for the Collection of Routine Customer Feedback”
TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the
subject of the request. (e.g., Comment card for soliciting feedback on xxxx)
PURPOSE: 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: Provide a brief description of the targeted group or
groups for this collection of information. These groups must have experience with the program.
TYPE OF COLLECTION: Check one box. If you are requesting approval of other
instruments under the generic, you must complete a form for each instrument.
CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the
collection will be returned as improperly submitted or it will be disapproved.
Personal 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.
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: Provide the Annual burden hours: Multiply the Number of responses and the
participation time and divide by 60.
FEDERAL COST: Provide an estimate of the annual cost to the Federal government.
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.
Please make sure that all instruments, instructions, and scripts are submitted with the
request.

4