Request for Service Delivery

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-1050)

Instruction: This form should be completed by the primary contact person from the Program sponsoring the collection.

DETERMINE IF YOUR COLLECTION IS APPROPRIATE FOR THIS GENERIC CLEARANCE MECHANISM:

Instruction: Before completing and submitting this form, determine first if the proposed collection is consistent with the scope of the Collection of Routine Customer Feedback generic clearance mechanism. To determine the appropriateness of using the Collection of Routine Customer Feedback generic clearance mechanism, complete the checklist below.

If you select “yes” to all criteria in Column A, the Collection of Routine Customer Feedback generic clearance mechanism can be used. If you select “yes” to any criterion in Column B, the Collection of Routine Customer Feedback generic clearance mechanism cannot be used.

Column A	Column B
The information gathered will only be used internally to CDC. [X] Yes [ ] No	Information gathered will be publicly released or published. [ ] Yes [X] No
Data is qualitative in nature and not generalizable to people from whom data was not collected. [X] Yes [] No	Employs quantitative study design (e.g. those that rely on probability design or experimental methods) [ ] Yes [X] No
There are no sensitive questions within this collection (e.g. sexual orientation, gender identity). [X] Yes [ ] No	Sensitive questions will be asked (e.g. sexual orientation, gender identity). [ ] Yes [X] No
Collection does not raise issues of concern to any other Federal agencies. [X] Yes [ ] No	Other Federal agencies may have equities or concerns regarding this collection. [ ] Yes [X] No
Data collection is focused on determining ways to improve delivery of services to customers of a current CDC program. [X] Yes [ ] No	Data will be used to inform programmatic or budgetary decisions, for the purpose of program evaluation, for surveillance, for program needs assessment, or for research. [ ] Yes [X] No
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. [X] Yes [ ] No

Did you select “Yes” to all criteria in Column A?

If yes, the Collection of Routine Customer Feedback generic clearance mechanism may be appropriate for your investigation. You may proceed with this form.

Did you select “Yes” to any criterion in Column B?

If yes, the Collection of Routine Customer Feedback generic clearance mechanism is NOT appropriate for your investigation. Stop completing this form now.

Note: Use OMB format when asking race/ethnicity as well as gender questions.

TITLE OF INFORMATION COLLECTION: Feedback on the use of the CDC Guideline for Prescribing Opioids for Chronic Pain.

PURPOSE:

In 2016, CDC developed and published the CDC Guideline for Prescribing Opioids for Chronic Pain to provide recommendations for the prescribing of opioid pain medication for patients 18 years and older in primary care settings. Improving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse or overdose from these drugs. It is therefore vital for CDC to help equip clinicians and health systems with the most updated guidance related to managing patients with chronic pain safely. The purpose of this project is to inform CDC’s understanding of stakeholders’ values and preferences related to pain and pain management and will complement CDC’s ongoing work assessing the need for updating and expanding the CDC Guideline for Prescribing Opioids for Chronic Pain.

In response to the opioid overdose epidemic, there have been a myriad of national, state and local responses. Given the multitude of guidelines and recommendations affecting practice, it is critical to understand the effect of these various changes on the care of patients with chronic pain and on clinicians’ beliefs, attitudes, and behaviors, including the benefits and unintended consequences for patients and clinicians alike. This project is non-research; using online survey “Feedback OpioidGuide” (Att. 1& 1a), results are non-generalizable and will be used internally to improve service delivery around the CDC Guideline for Prescribing Opioids for Chronic Pain. The feedback collected from this assessment will inform a three phase process to evaluate the implementation of the CDC Guideline for Prescribing Opioids for Chronic Pain and ultimately lead to a full evaluation (phase three), which will include a full ICR- OMB submission. Information gathered will be used internally for general service improvement, and to inform the phase three OMB evaluation submission. Without these types of feedback, the Agency will not be able to improve current and future resources to meet clinician and health system needs.

DESCRIPTION OF RESPONDENTS:

Respondents will include volunteers from health systems across 45 states that are members of the American Medical Group Association (AMGA), and who are the most appropriate population to access this type of feedback. It is essential to gain feedback on guidelines and recommendations that have been implemented to promote safer prescribing of prescription opioids to treat chronic pain from this subpopulation within health systems.

TYPE OF COLLECTION: (Check one)

Instruction: Please sparingly use the Other category

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

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

[ ] Focus Group [X] Other: Online Feedback

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.

Name:______________Karen Angel_______________________________

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 [ X] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [X ] No

Privacy Act does not apply for this information collection request (Attachment 2). Personal Private Information is not collected. All data will be reported in aggregate unlinked form. Participants will be selected from the previously collected information of members of the American Medical Group Association (AMGA). All procedures have been developed, in accordance with federal, state, and local guidelines, to ensure that the rights and privacy of respondents will be protected and maintained.

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [X] No

If Yes: Please describe the incentive. If amounts are outside of customary incentives, please also provide a justification.

BURDEN HOURS

Category of Respondent	Form name	No. of Respondents	Participation Time (Hours)	Burden
AMGA members	Online Feedback OpioidGuide (Att. 1)	100	25/60	25
Totals				25

FEDERAL COST: The estimated annual cost to the Federal government is $ 3,000

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?

If Yes: Please provide a description of both below (or attach the sampling plan)

If No: Please provide a description of how you plan to identify your potential group of respondents and how you will select them or ask them to self-select/volunteer

AMGA will narrow their list of members with whom we have discussed this particular project, who have presented at AMGA meetings or conferences on Chronic Pain Management or Opioids, or who have expressed interest in the topic area.

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.

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