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 0920-0953 Extramural Communication Community of Practice-feedback	Form and Instruction	New	Repair queued
Virtual TA Survey	Form	New	Available
Field TA Survey	Form	New	Available
Form 0920-0953 Telehealth Services Satisfaction Questionnaire	Form	New	Repair queued
Form 0920-0953 Webinar Questions	Form and Instruction	New	Available
Form 0920-20OY Fact sheet testing interview instrument	Form and Instruction	New	Available
Form 0920-0953 WTC Environmental Health Center Customer Satisfaction Survey	Form	New	Available
Form 0920-0953 Focus Group Discussion Guide For Employees	Form and Instruction	New	Available
Form 0920-0953 Focus Group Discussion Guide For Employers	Form and Instruction	New	Available
Form 0920-0953 TMH QA Questionnaire	Form and Instruction	New	Available
Form 0920-0953 Cross-Sector Survey	Form and Instruction	New	Available
Feedback Survey on the "Expanding Research Partnerships" webinar series	Form and Instruction	New	Available
Feedback Survey on the "Expanding Research Partnerships" webinar series	Form and Instruction	New	Available
Feedback Survey on the "Expanding Research Partnerships" webinar series	Form and Instruction	New	Available
Form 0920-0953 Work History	Form	New	Available
Form 0920-0953 Longest Held Occupation	Form	New	Available
Form 0920-0953 Employment Status & Retirement dates	Form	New	Available
Form 0920-0953 Occupational Data for Health (OHD) Phototype Version 3	Form and Instruction	New	Available
Form 0920-0953 POST-TEST SURVEY FOR OCCUPATIONAL DATA FOR HEALTH (ODH)	Form	New	Available
Form 0920-0953 PRE-TEST DEMOGRAPHIC DATA SURVEY FOR OCCUPATIONAL DATA FOR HEALTH (ODH) PROTOTYPE USABILITY TESTING	Form	New	Available
Feedback Survey on the "Expanding Research Partnerships" webinar series	Form and Instruction	New	Available
Grantee Meeting Evaluation	Form	New	Available
Form 0920-0953 WTC Mt. Sinai Medical Center Annual Survey	Form and Instruction	New	Available
Telehealth Services Patient Satisfaction Questionnaire	Form and Instruction	New	Available
Form 0920-0953 Rutgers Patient Satisfaction Survey 2019	Form and Instruction	New	Available
World Trade Center Health Program Nutrition Survey	Form and Instruction	New	Available
Member Satisfaction Survey	Form	New	Available
Form 0920-0953 Telehealth Satisfaction Survey	Form and Instruction	New	Available
Treament Satisfaction Survey - Spanish	Form	New	Available
Treatment Satisfaction Survey - English	Form	New	Available
Form 0920-0953 Representative Question Stems for Interviews	Form and Instruction	New	Available
Form 0920-0953 Opening Script and Eligibility Screening Form	Form and Instruction	New	Available
Form 0920-0953 Participation in WTC Health Program at NYUSOM Clinical Center of Excellence (Spanish Version)	Form	New	Available
Form 0920-0953 Participation in WTC Health Program at NYUSOM Clinical Center of Excellence	Form	New	Available
Systems Application Feedback	Form	New	Available
Focus Group Discussion Guide for Online Workplace Violence Prevention Best Practices Courses	Form and Instruction	New	Available
Form 0920-0953 Patient Satisfaction Survey	Form	New	Available
Member Questionnaire - Spanish	Form and Instruction	New	Available
Member Questionnaire - Polish	Form and Instruction	New	Available
Member Questionnaire - English	Form and Instruction	New	Available
Form 0920-0953 Worker Notification Feedback Survey	Form and Instruction	New	Available
Barriers to Care Assessment	Form	New	Available
NIOSH Part SS-A 6.7.18.docx	Supporting Statement A	Uploaded 2018-06-21	Available
60-day FRN.pdf	Supplementary Document	Uploaded 2018-04-30	Available
Fast_Track_GenIC_RequestTemplate.docx	Supplementary Document	Uploaded 2018-02-08	Available
NIOSH Part SS-B 1 29 18.docx	Supporting Statement B	Uploaded 2018-02-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
245944	Focus Groups to Obtain Input from Construction Workers and Employers	Other-Spanish Version	New
245765	Survey to solicit feedback on Extramural Communication Community of Practice Meetings	Form and Instruction	New	Extramural Communication Community of Practice-feedback
244984	Survey for webinars hosted by NIOSH ORI	Other-WORD	New
244558	Focus groups to obtain input from construction workers and employers	Other-Focus group guide	New
244466	Survey to Solicit Feedback on TA on Worker Safety and Health provided as part of COVID response	Form	New	Virtual TA Survey
244466	Survey to Solicit Feedback on TA on Worker Safety and Health provided as part of COVID response	Form	New	Field TA Survey
243427	Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire	Form	New	Telehealth Services Satisfaction Questionnaire
242833	TWH Webinar Series	Form and Instruction	New	Webinar Questions
242116	Interviews to solicit feedback on COVID-19 Worker Factsheets	Form and Instruction	New	Fact sheet testing interview instrument
241811	Occupational Exposure Banding Survey	Other-WORD	New
240895	NYC Health + Hospitals World Trade Center Environmental Health Center Customer Satisfaction Survey	Form	New	WTC Environmental Health Center Customer Satisfaction Survey
240720	Focus Groups-retain Employers	Form and Instruction	New	Focus Group Discussion Guide For Employees
240720	Focus Groups-retain Employers	Form and Instruction	New	Focus Group Discussion Guide For Employers
239432	Telehealth Satisfaction at MSSM	Form and Instruction	New	TMH QA Questionnaire
238921	Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire	Other-WORD.doc	New
238377	NORA CRC Cross-Sector Council Questionnaire	Form and Instruction	New	Cross-Sector Survey
237984	Survey to Solicit Feedback on Expanding Research Partnerships: Federal Govt	Form and Instruction	New	Feedback Survey on the "Expanding Research Partnerships" webinar series
237983	Survey to Solicit Feedback on Expanding Research Partnerships: State/Local/Tribal Govt	Form and Instruction	New	Feedback Survey on the "Expanding Research Partnerships" webinar series
237982	Survey to Solicit Feedback on Expanding Research Partnerships: Private Sector	Form and Instruction	New	Feedback Survey on the "Expanding Research Partnerships" webinar series
237926	Occupational Data for Health (ODH) Prototype usability testing	Form	New	Work History
237926	Occupational Data for Health (ODH) Prototype usability testing	Form	New	Longest Held Occupation
237926	Occupational Data for Health (ODH) Prototype usability testing	Form	New	Employment Status & Retirement dates
237926	Occupational Data for Health (ODH) Prototype usability testing	Form and Instruction	New	Occupational Data for Health (OHD) Phototype Version 3
237926	Occupational Data for Health (ODH) Prototype usability testing	Form	New	POST-TEST SURVEY FOR OCCUPATIONAL DATA FOR HEALTH (ODH)
237926	Occupational Data for Health (ODH) Prototype usability testing	Form	New	PRE-TEST DEMOGRAPHIC DATA SURVEY FOR OCCUPATIONAL DATA FOR HEALTH (ODH) PROTOTYPE USABILITY TESTING
237926	Occupational Data for Health (ODH) Prototype usability testing	Other-Footer	New
237902	Survey to Solicit Feedback on Expanding Research Partnerships: Individuals	Form and Instruction	New	Feedback Survey on the "Expanding Research Partnerships" webinar series
237772	2019 NIOSH Centers Grantee Meeting Evaluation Survey	Form	New	Grantee Meeting Evaluation
237578	Mount Sinai World Trade Center Health Program Clinical Center of Excellence Annual Satisfaction Survey	Form and Instruction	New	WTC Mt. Sinai Medical Center Annual Survey
236605	Telehealth Satisfaction at Mt. Sinai School of Medicine (MSSM)	Form and Instruction	New	Telehealth Services Patient Satisfaction Questionnaire
236603	EOHSI/Rutgers Clinical Center of Excellence Annual Monitoring Exam Patient Satisfaction Survey	Form and Instruction	New	Rutgers Patient Satisfaction Survey 2019
236078	Customer Survey for the World Trade Center Health Program Nutrition Department (Stony Brook)	Form and Instruction	New	World Trade Center Health Program Nutrition Survey
235814	Course Evaluation for Continuing Education Webinars-WTCHP	Other-WORD	New
235413	Member Satisfaction Survey - Stony Brook	Form	New	Member Satisfaction Survey
235412	Telehealth Satisfaction at MSSM	Form and Instruction	New	Telehealth Satisfaction Survey
235409	Treatment Satisfaction Survey - NYU	Form	New	Treament Satisfaction Survey - Spanish
235409	Treatment Satisfaction Survey - NYU	Form	New	Treatment Satisfaction Survey - English
235160	Winch Entanglement Prevention Technology Interviews	Form and Instruction	New	Representative Question Stems for Interviews
235160	Winch Entanglement Prevention Technology Interviews	Form and Instruction	New	Opening Script and Eligibility Screening Form
234904	Patient Satisfaction Survey Stony Brook	Form	New	Participation in WTC Health Program at NYUSOM Clinical Center of Excellence (Spanish Version)
234904	Patient Satisfaction Survey Stony Brook	Form	New	Participation in WTC Health Program at NYUSOM Clinical Center of Excellence
233405	Surveillance Systems Feedback Survey	Form	New	Systems Application Feedback
233232	Three Occupation-specific Units for the Workplace Violence Course: Focus Group Discussions for the Stand-alone Facilities, Home Health/Social Services, and Emergency Responder Units	Form and Instruction	New	Focus Group Discussion Guide for Online Workplace Violence Prevention Best Practices Courses
233061	Patient Satisfaction Survey Stony Brook	Form	New	Patient Satisfaction Survey
232998	Barriers to Care Assessment for WTC Health Program Care at Mt. Sinai	Form and Instruction	New	Member Questionnaire - Spanish
232998	Barriers to Care Assessment for WTC Health Program Care at Mt. Sinai	Form and Instruction	New	Member Questionnaire - Polish
232998	Barriers to Care Assessment for WTC Health Program Care at Mt. Sinai	Form and Instruction	New	Member Questionnaire - English
232892	Worker Notification Feedback Survey	Form and Instruction	New	Worker Notification Feedback Survey
232864	Barriers to Care Assessment for WTC Health Program Care at MSSM	Form	New	Barriers to Care Assessment

ICR Details

OMB Control No: 0920-0953	ICR Reference No: 201802-0920-007
Status: Historical Active	Previous ICR Reference No: 201505-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0953
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 without change	Conclusion Date: 08/27/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/27/2018
Terms of Clearance: 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.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2021	36 Months From Approved	08/31/2018
Responses	154,800	0	229,800
Time Burden (Hours)	39,225	0	57,975
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information is necessary to enable the CDC/NIOSH to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The types of collections that this generic clearance covers include, but are not limited to: Customer comment cards/complaint forms, Small discussion groups, Focus Groups of customers, potential customers, delivery partners, or other stakeholders, Cognitive laboratory studies, such as those used to refine questions or assess usability of a website, Qualitative customer satisfaction surveys (e.g., post-transaction surveys; opt-out web surveys) and In-person observation testing (e.g., website or software usability tests).

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
   PL: Pub.L. 91 - 596 20 Name of Law: Occupational Safety and Health Act of 1970
  

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:
	83 FR 12766	03/23/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 29558	06/25/2018
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 36

table that charts list of burden

IC Title	Form No.	Form Name
2019 NIOSH Centers Grantee Meeting Evaluation Survey	none	Grantee Meeting Evaluation
Barriers to Care Assessment for WTC Health Program Care at MSSM	none	Barriers to Care Assessment
Barriers to Care Assessment for WTC Health Program Care at Mt. Sinai	none, none, none	Member Questionnaire - English ,   Member Questionnaire - Polish ,   Member Questionnaire - Spanish
Course Evaluation for Continuing Education Webinars-WTCHP
Customer Survey for the World Trade Center Health Program Nutrition Department (Stony Brook)	n/a	World Trade Center Health Program Nutrition Survey
EOHSI/Rutgers Clinical Center of Excellence Annual Monitoring Exam Patient Satisfaction Survey	0920-0953	Rutgers Patient Satisfaction Survey 2019
Focus Groups to Obtain Input from Construction Workers and Employers
Focus Groups-retain Employers	0920-0953, 0920-0953	Focus Group Discussion Guide For Employers ,   Focus Group Discussion Guide For Employees
Focus groups to obtain input from construction workers and employers
Interviews to solicit feedback on COVID-19 Worker Factsheets	0920-20OY	Fact sheet testing interview instrument
Member Satisfaction Survey - Stony Brook	none	Member Satisfaction Survey
Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire	0920-0953	Telehealth Services Satisfaction Questionnaire
Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire
Mount Sinai World Trade Center Health Program Clinical Center of Excellence Annual Satisfaction Survey	0920-0953	WTC Mt. Sinai Medical Center Annual Survey
NORA CRC Cross-Sector Council Questionnaire	0920-0953	Cross-Sector Survey
NYC Health + Hospitals World Trade Center Environmental Health Center Customer Satisfaction Survey	0920-0953	WTC Environmental Health Center Customer Satisfaction Survey
Occupational Data for Health (ODH) Prototype usability testing	0920-0953, 0920-0953, 0920-0953, 0920-0953, 0920-0953, 0920-0953	PRE-TEST DEMOGRAPHIC DATA SURVEY FOR OCCUPATIONAL DATA FOR HEALTH (ODH) PROTOTYPE USABILITY TESTING ,   POST-TEST SURVEY FOR OCCUPATIONAL DATA FOR HEALTH (ODH) ,   Occupational Data for Health (OHD) Phototype Version 3 ,   Employment Status & Retirement dates ,   Longest Held Occupation ,   Work History
Occupational Exposure Banding Survey
Patient Satisfaction Survey Stony Brook	0920-0953, 0920-0953	Participation in WTC Health Program at NYUSOM Clinical Center of Excellence ,   Participation in WTC Health Program at NYUSOM Clinical Center of Excellence (Spanish Version)
Patient Satisfaction Survey Stony Brook	0920-0953	Patient Satisfaction Survey
Surveillance Systems Feedback Survey	none	Systems Application Feedback
Survey for webinars hosted by NIOSH ORI
Survey to Solicit Feedback on Expanding Research Partnerships: Federal Govt	n/a	Feedback Survey on the "Expanding Research Partnerships" webinar series
Survey to Solicit Feedback on Expanding Research Partnerships: Individuals	n/a	Feedback Survey on the "Expanding Research Partnerships" webinar series
Survey to Solicit Feedback on Expanding Research Partnerships: Private Sector	n/a	Feedback Survey on the "Expanding Research Partnerships" webinar series
Survey to Solicit Feedback on Expanding Research Partnerships: State/Local/Tribal Govt	n/a	Feedback Survey on the "Expanding Research Partnerships" webinar series
Survey to Solicit Feedback on TA on Worker Safety and Health provided as part of COVID response	none, none	Field TA Survey ,   Virtual TA Survey
Survey to solicit feedback on Extramural Communication Community of Practice Meetings	0920-0953	Extramural Communication Community of Practice-feedback
TWH Webinar Series	0920-0953	Webinar Questions
Telehealth Satisfaction at MSSM	0920-0953	TMH QA Questionnaire
Telehealth Satisfaction at MSSM	0920-0953	Telehealth Satisfaction Survey
Telehealth Satisfaction at Mt. Sinai School of Medicine (MSSM)	n/a	Telehealth Services Patient Satisfaction Questionnaire
Three Occupation-specific Units for the Workplace Violence Course: Focus Group Discussions for the Stand-alone Facilities, Home Health/Social Services, and Emergency Responder Units	n/a	Focus Group Discussion Guide for Online Workplace Violence Prevention Best Practices Courses
Treatment Satisfaction Survey - NYU	none, none	Treatment Satisfaction Survey - English ,   Treament Satisfaction Survey - Spanish
Winch Entanglement Prevention Technology Interviews	0920-0953, 0920-0953	Opening Script and Eligibility Screening Form ,   Representative Question Stems for Interviews
Worker Notification Feedback Survey	0920-0953	Worker Notification Feedback Survey

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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	154,800	229,800	0	-75,000	0	0
Annual Time Burden (Hours)	39,225	57,975	0	-18,750	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: Burden reduction due to adjusting for unused hours and planned efforts within NIOSH for next three years.

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Annual Cost to Federal Government: $112,000

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 06/27/2018

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