Template with Project Description

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.

TITLE OF INFORMATION COLLECTION:

An assessment of the feasibility and sustainability of CDC Zika activities funded under the USAID/CDC Interagency Agreement

PURPOSE:

At the height of the Zika epidemic, USAID and CDC entered into an Interagency Agreement (IAA) committed to minimizing the number of pregnancies affected by Zika virus (ZIKV) infection, and improve our understanding of ZIKV to predict the long-term consequences on affected countries and at-risk populations, including the United States. Collectively, feedback from stakeholders concerning the effectiveness, efficiency and experiences with general service delivery, support and strategies needed to carry out the Zika objectives stated in the IAA and subsequent scopes of works (SOWs) has not been collected. To this end, CDC will collect, analyze, and interpret information gathered through this generic clearance to help identify means of improving services and collaborations with global partners and also explore lessons learned including the feasibility and sustainability of ZIKV activities funded under the USAID/CDC Zika IAA

DESCRIPTION OF RESPONDENTS:

The assessment will include interviews with key stakeholders that would have interest in and value the information, including, but not limited to those involved in the implementation of Zika-related activities funded under the IAA. These respondents will include ministerial and in-county administrative officials, members of USAID Missions involved in Zika implementation, regional partners, in-country implementing partners and others involved in proceedings related to Zika activities funded under the IAA.

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: Interviews

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: Elizabeth O’Mara Sage, PhD, MPH

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

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

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Recipients and implementing partners of the Zika IAA funding	25	1 Hour	25 hours
Totals	25	1 hour	25 hours

FEDERAL COST: The estimated annual cost to the Federal government is approximately $50,000 as approved under the USIAD/CDC Zika interagency agreement under the authority of Section 632(b) of the Foreign Assistance Act of 1961, as amended.

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

The customer list includes a selection of targeted respondents based on suggestions from CDC and USAID subject matter experts who have worked alongside and closely with these stakeholders involved in the implementation of Zika activities. Respondents for this purpose have been identified, notified and are in compliance with the one-hour time commitment.

In-person interviews with respondents will be conducted by members of the CDC Zika Coordination Unit located in the Center for Global Health Science Office. The use of an interview guide will assist the interviewer in exploring respondent perspectives about IAA execution and administration; their opinions regarding partnerships and health diplomacy; and, the best way to proceed if confronted with another similar urgent public health scenario. Others areas of key informant interviews may focus on specific Zika activities, as appropriate.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[X] In-person

[ ] Mail

[ ] Other, Explain

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

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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