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:

DELTA Impact 2020 Reverse Site Visit Customer Feedback

PURPOSE:

NCIPC - CDC has funded the Domestic Violence Prevention Enhancements and Leadership Through Alliances (DELTA) Program since 2002. The DELTA program funds State Domestic Violence Coalitions to implement statewide Intimate Partner Violence (IPV) prevention efforts, while also providing assistance and funding for local communities to implement IPV prevention activities.

NCIPC – CDC funds various state and local recipients to implement and evaluate violence prevention programs through the DELTA program. As part of these agreements, CDC sponsors activities to support recipients with implementation and/or assessment of their initiatives. CDC NCIPC provides technical assistance, sponsors training events, develops training resources, and supports the funded awardees in the field. One of these events was the DELTA Impact Virtual 2020 Reverse Site Visit (August 11-13, 2020).

The purpose of this request is to gather timely feedback from individuals who attend the DELTA Impact Virtual 2020 Reverse Site Visit. The Virtual Reverse Site Visit provides program recipients with opportunities to receive technical assistance on the implementation, evaluation, and sustainability of violence prevention strategies. Feedback gathered, including satisfaction with delivery and content, will help CDC-NCIPC work with the recipients to better understand the capacity of and supports needed by the recipients. The information collected will also provide a feedback mechanism to identify areas of improvement for future reverse site visits and technical assistance efforts. Participant feedback is vital to ensure learning opportunities are beneficial for participants, and without such data collection this information would be unknown.

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:

Respondents are individuals who attend DELTA Impact Virtual Reverse Site Visit. Participants include representatives from the funded State Domestic Violence Coalitions, subrecipients, and contractors responsible for implementing and evaluating violence prevention programs and strategies. The customer list will consist of the attendees of the Reverse Site Visit. Each DELTA Impact funding recipient was allowed six representatives to participate in the meeting. No sampling will be conducted in order to gather feedback from any meeting participant who is willing to volunteer feedback.

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:________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 (Attachment 3). 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

BURDEN HOURS

Category of Respondent	Form Name	No. of Respondents	Participation Time (Hours)	Burden hours
DELTA Impact Virtual Reverse Site Visit Participants	Email invitation (Att. 2)	60	5/60	5
	2020 Reverse Site Visit Feedback Form (Att.1)	60	10/60	10
Totals 15

FEDERAL COST: The estimated annual cost to the Federal government is $1,000

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?

The target respondents will be participants of the 2020 Reverse Site Visit. There will be up to 60 DELTA Impact recipients in attendance. A link to the Survey Monkey “2020 Reverse Site Visit Feedback Form” (Attachment 1) will be invited through an email (Attachment 2) to participants upon. Participation in the data collection will be voluntary.

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

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