Request for Approval

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 interviews to improve technical assistance

PURPOSE:

In response to the growing severity of the opioid overdose epidemic, the US government declared the opioid overdose epidemic a public health emergency on October 26, 2017. CDC’s Opioid Rapid Response Teams (ORRTs) are one of five “Big Idea” projects identified by the US Department of Health and Human Services’ (HHS) Office of the Assistant Secretary for Health (OASH) to address the opioid overdose epidemic. ORRTs consist of teams of trained staff that provide specialized surge support to local communities that need additional public health capacity to respond to opioid overdoses and related harms.

The purpose of this request is to gain information from state health departments and behavioral health authorities about their capacity and preparation efforts to respond to law enforcement actions (such as clinic closures). This request will be used to collect details about health departments' responses to upcoming law enforcement actions against pain clinics. The interviews will be conversations about states’ ability to respond to pending law enforcement actions, such as clinic closure. The purpose of this data collection will be to improve the technical assistance provided with the Opioid Rapid Response Team (ORRT) when working with state and territorial health departments.

ORRT’s role is to facilitate connection with state health departments and behavioral health authorities to establish a public health response, ensuring that patients of clinics closed by law enforcement do not fall out of care. CDC’s role will be to share any information about the upcoming law enforcement action (after consulting with law enforcement partners) and provide technical assistance to states. Additionally, this information will inform the ORRT core team’s future support to state health departments and behavioral health authorities when responding to pending clinic closures. CDC will ask about how can CDC provide better technical assistance.

Findings will be used internally by CDC to improve CDC services. Information gathered will not be used for the purpose of substantially informing influential policy decisions. Without this type of feedback, the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control will not have timely information to adjust its services to meet customer needs.

DESCRIPTION OF RESPONDENTS:

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 [X] 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.

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

This submission has been reviewed by the CDC NCIPC’s Information Systems Security Officer, who has determined that the Privacy Act does not apply. (Att. 2). Information of participants was previously collected. CDC will not have access to or receive any personally identifiable information (PII) about participants.

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 hours
State Health Department and Behavioral Health officials	Feedback Moderator Guide (Att.1)	500	30/60	250
Totals				250

FEDERAL COST: The estimated annual cost to the Federal government is $5,0000

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 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

Potential respondents are previously identified contacts in positions of leadership at state public health departments and local health authorities.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ x] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ x ] Yes [] No

A trained moderator will conduct the phone interviews using the Feedback Moderator Guide (Att. 2). The interviews will be conversations about states’ ability to respond to pending law enforcement actions, such as clinic closure.

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