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. [ ] Yes [X ] 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: Pilot Survey of the Applying CDC’s Guidelines for Prescribing Opioids Online Training and Updated Post Course Evaluation

PURPOSE: Drug overdose involving opioids, including prescription and illicit opioids, is a leading cause of injury-related death in the United States. In response to the critical need for evidence-based opioid prescribing guidance, the Centers for Disease Control and Prevention (CDC) published the “Guideline for Prescribing Opioids for Chronic Pain1” in 2016 to offer recommendations for safer, more effective opioid prescribing for chronic pain in patients 18 and older in outpatient settings outside of active cancer treatment, palliative care, and end-of-life care.

To support healthcare providers in applying the recommendations in clinical settings, CDC’s Division of Unintentional Injury Prevention now the Division of Overdose Prevention (DOP) in the National Center for Injury Prevention and Control (NCIPC) developed the interactive online training series, “Applying CDC’s Guideline for Prescribing Opioids”. The training consists of stand-alone modules that use patient scenarios, knowledge checks, and communication tips to help providers better understand how to use the evidence-based recommendations to improve clinical decision making for the management of chronic pain, including weighing the risks and benefits of using opioid therapy

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 to substantially inform influential policy decisions. The information collected will be used to better understand 1) the learns experience with the trainings 2) how well the trainings met their learning needs 3) additional training needs. Without these types of feedback, the Agency will not have timely information to adjust its services to meet customer needs.

CDC’s Training and Continuing Education Office has reviewed all materials in the post course evaluation for all the modules in the “Applying CDC’s Guideline for Prescribing Opioids.”We would like to incorporate one additional question to the already approved standard course evalautaion survey developed and implemented by TCEO (OMB Control No. 0920-0017)

This question is currently being used in TCEO Clinician Outreach and Communication Activity course evaluation. This question will only be used internally to help us better direct the training through communication channels used by the intended audience.

DESCRIPTION OF RESPONDENTS: Respondents are individuals who voluntarily completed module one (Addressing the Opioid Epidemic: Recommendations from CDC) in the “Applying CDC’s Guideline for Prescribing Opioids” interactive training series. Participants might include any learner who have an interest in learning about opioid prescribing and completed the module, including physicians, nurses, and other healthcare and public health professionals. The intended responders for the add-on TCEO question are healthcare professionals, including physicians, nurses, pharmacists, physician assistants, and public health professionals who have an interest in opioid prescribing.

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 to substantially inform 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

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
Module 1: 3 Month Follow Up Survey (Att. A)	100	10/60	17
Totals	100	10/60	17

FEDERAL COST: The estimated annual cost to the Federal government is __$4,000.

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? [ ] 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

Respondents are individuals who voluntarily completed module one in the “Applying CDC’s Guideline for Prescribing Opioids” interactive training series. We will invite the first 100 learners who completed module one beginning January 1, 2020, and where 3 months has passed since completion, to participate in the study.

The 3-month follow up survey will consist of 12 questions (9 closed-ended and 3 open-ended) [Attachment A]. Questions are structured to help obtain information on participants’ prescribing practices; knowledge retention of the prescribing guideline recommendations; and perceived barriers and facilitators to implementing recommended practice changes. No personally identifiable information will be collected. The 3-month follow up survey will take about ten minutes to complete. There will be no direct costs to respondents other than their time to complete the survey.

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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