GENIC 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.

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

TITLE OF INFORMATION COLLECTION: WISQARS Data Visualization Usability Testing Customer Feedback

PURPOSE:

The Web-based Injury Statistics Query and Reporting System (WISQARS) is an interactive Internet-based injury data system. Users can search, sort, and view the injury data and create reports, charts, maps, and slides. CDC’s National Center for Injury Prevention and Control (NCIPC) conducted a portfolio review of WISQARS in 2015 showing the web site receives on average 2,150 visits per day. The WISQARS web site is used extensively by a variety of audiences. The information and data needs vary among these groups but WISQARS can serve them all by enhancing visual data interpretations.

The purpose of this survey is to obtain additional information on user satisfaction with the WISQARS web site. The information collected will be used to improve the content and functionality of the web site. Feedback gathered, including satisfaction with delivery and content, will be used to improve the organization of the web pages and determine any gaps in information. The information collected will help identify areas of improvement without such data collection this information would be unknown. Participation in the survey will be voluntary. Users will provide feedback to CDC through an online survey.

Information gathered will be used only internally for general service improvement and is not intended for release outside of the agency. Information gathered will not be used for the purpose of substantially informing influential policy decisions. Without this type of feedback, the Agency will not have timely information to adjust its services to meet customer needs.

DESCRIPTION OF RESPONDENTS:

WISQARS is used by a variety of audiences, including public health professionals, scientists/researchers, students, health care providers, and teachers/educators. Participation in the survey is voluntary.

TYPE OF COLLECTION: (Check one)

Instruction: Please sparingly use the Other category

[ ] 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.

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

Personally, identifiable information (PII) is not collected ( Att 2) . No questions will be asked that are of a personal or sensitive nature. Participants to the survey are already registered with an online panel provider. Information of participating panelists was previously collected by the online panel provider and will not be included on the dataset submitted to CDC. At no time does CDC have access or will receive potentially identifiable information. At no time is this information linked or linkable to usability testing information. All procedures have been developed, in accordance with federal, state, and local guidelines, to ensure that the rights and privacy of participants 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 Respondents	No. of Respondents	Participation Time (hours)	Burden (hours)
WISQARS Online Survey	450	10 minutes	75
Total			75

FEDERAL COST: The estimated annual cost to the Federal government is $5,999

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? [ ] Yes [X ] 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

A link to the online survey will be placed on the WISQARS web site. It will be highlighted in a call out box that says “We welcome your feedback. Help us improve your experience by taking our short survey.” Users can then decide to voluntarily complete the online survey. Links to the survey tool will also be shared through an email newsletter to state partners

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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