Request for Approval

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-0953)

TITLE OF INFORMATION COLLECTION: Course Evaluations for the five continuing education webinars for Screening and Treatment of Responders and Survivors and the WTC Health Program. Courses include:

• Cancer and the World Trade Center Health Program

• Advances in the Screening and Treatment for WTC Responders and Survivors

• Airway, Digestive, and Mental Health Comorbidities in WTC Responders and Survivors

• Health Risks Associated with 9/11 and the WTC Disaster: Lessons Learned

• After the 9/11 Terrorist Attacks: The World Trade Center Health Program and Disaster Response

PURPOSE: Every two years the WTC Health program training courses expire and need to be renewed in CDC Train. These evaluations are used to assess the learning experience, improve course content and enhance the quality of the course material.

DESCRIPTION OF RESPONDENTS: Administrators, Licenses Practical/ Vocational Nurses, MDs, Medical Assistants, Medical Students, Nurse Practitioners, Nurse Technicians, Other Health Educators, Pharmacists, Pharmacy Technicians, Physician Assistants, Program Managers, Registered Nurses

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[] Focus Group [X ] Other: Course Evaluation

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:_Emily Hurwitz_­__________________

To assist review, please provide answers to the following question:

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:

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	No. of Respondents	No. of Responses per Respondent	Avg. Burden per Response (in hrs.)	Total Burden Hours
Medical Professionals	Cancer and the World Trade Center Health Program	180	1	5/60	15
	Advances in the Screening and Treatment for WTC Responders and Survivors	180	1	5/60	15
	Airway, Digestive, and Mental Health Comorbidities in WTC Responders and Survivors	265	1	5/60	22
	Health Risks Associated with 9/11 and the WTC Disaster: Lessons Learned	100	1	5/60	8
	After the 9/11 Terrorist Attacks: The World Trade Center Health Program and Disaster Response	275	1	5/60	23
Total					83

Burden hours have been estimated based on data of respondents spanning all five WTCHP courses. We anticipate having the same or more respondents for future trainings. Each survey ranges from 32 to 39 questions.

FEDERAL COST: The estimated annual cost to the Federal government is _­$0____

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)?

Responses are tracked through CDC Train and Training and Continuing Education Online (TCEO). The following is a sampling of tracked data.

.

CE Type	Available CE	Registered	Completed	% Completed	Passed	% Passed	Total  CE Awarded
WB2811 - After the 9/11 Terrorist Attacks: The World Trade Center Health Program and Disaster Response (Web-based)
Audit	0.000	2	1	50.00%	1	100.00%	0.00
CEU  (other professionals)	0.100	61	44	72.13%	35	79.55%	3.50
CME  (physicians)	0.500	20	16	80.00%	15	93.75%	7.50
CME_NON  (attendance for non-physicians)	0.500	19	15	78.95%	14	93.33%	7.00
CME_PAR  (participation for non-physicians)	0.000	2	2	100.00%	2	100.00%	0.00
CNE  (nurses)	0.200	83	69	83.13%	61	88.41%	12.20
CPE  (pharmacists)	0.030	5	3	60.00%	3	100.00%	0.09
CPH  (public health professionals)	1.000	1	1	100.00%	1	100.00%	1.00
Total		193	151	78.24 %	132	87.42 %	31.29

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.

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.

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.

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.

6