Questionnaire Clearance Submission

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

TITLE OF INFORMATION COLLECTION: NORA CRC Cross-Sector Council Questionnaire

PURPOSE:

The Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH) seeks approval from the Office of Management and Budget (OMB) to collect information from a group of customers to determine preferences and priorities for future services and products. This data collection effort is focused on identifying future research priorities and communication products, which will be used to address the National Occupational Research Agenda for Cancer, Reproductive, Cardiovascular, and Other Chronic Disease Prevention (CRC).

The National Occupational Research Agenda (NORA) is a partnership program to stimulate innovative research and improved workplace practices. Unveiled in 1996, NORA has become a research framework for the nation (not NIOSH). Diverse parties collaborate to identify the most critical issues in workplace safety and health. Partners then work together to develop goals and objectives for addressing these needs. NIOSH and its partners have formed NORA councils, including participants from academia, industry, labor, and government. Each council is charged with developing a sector-specific research agenda for the nation. These agendas provide guidance to the entire occupational safety and health community for moving research to practice in workplaces. Council members then work together to address the agendas through information exchange, networking, and dissemination and implementation of solutions that work.

To ensure that plans for future council activities to address the National Occupational Research Agenda for (CRC) will satisfy our customers’ needs and result in improved services and products, NIOSH proposes to utilize a brief online questionnaire to collect information from council members to understand preferences and ideas for how to address the National Occupational Research Agenda for CRC through meetings and activities in the upcoming year. Completion of the questionnaire is strictly voluntary and the limited number of questions and time required to complete the questionnaire will result in a low burden to the participants. The questionnaire will not collect personally identifiable information. Results from the questionnaire will be used to facilitate a discussion with the same group of council members to further refine plans for upcoming meetings and activities, resulting in an agenda for the council to move forward with addressing the National Occupational Research Agenda for CRC through information exchange, networking, and enhanced dissemination and implementation of solutions that work. The results will not be disseminated publically or used for program evaluation.

DESCRIPTION OF RESPONDENTS:

Respondents will include current members of the NORA CRC Cross-Sector Council and other partners who have expressed an interest in participating in the NORA CRC Cross-Sector Council and committed to participating in the next meeting of this group. The council membership reflects that diversity of companies, associations, unions, and other agencies with an interest in worker safety and health in the services industry. In total, this group is comprised of 21 individuals representing industry, government, academia, and labor. Responses to the questions will facilitate the development of the National Occupational Research Agenda for CRC as well as subsequent meetings of this council.

TYPE OF COLLECTION: (Check one)

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

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

[] Focus 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: Todd Stueckle, PhD

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

Category of Respondent	No. of Respondents	No. of Responses per Respondent	Participation Time (per Respondent)	Burden (hours)
Private Sector	9	1	25/60	4
State, local, or tribal governments	4	1	25/60	2
Federal employees	8	1	25/60	3
Total				9

FEDERAL COST: The estimated annual cost to the Federal government is $200 (personnel time)

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?

Participation will be completely voluntary and respondents will receive no monetary incentive for participation. All current members of the NORA CRC Cross-Sector Council and others who have expressed interest in participating in this council will be invited to participate. Information about the council and meetings are posted on the NIOSH website, ensuring all interested parties have the opportunity to opt into these meetings.

Data collection:

1. An introductory email and link to the questionnaire will be sent to each participant (see Attachment 1 for draft introductory email);

2. The questionnaire will take up to 25 minutes to complete (see Attachment 2 for draft questionnaire);

3. Results will be automatically saved so that respondents will not need to return their responses to NIOSH, thus ensuring confidentiality and low burden.

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

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.

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