CDC/ATSDR Formative Research and Tool Development

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-1154 Focus Group Guide: Youth	Form and Instruction	New	Repair queued
Form 0920-1154 Consent Form - Parent of Youth Participant	Form and Instruction	New	Repair queued
Form 0920-1154 Focus Group Recruitment Materials - Youth	Form and Instruction	New	Repair queued
Form 0920-1154 Focus Group Guide: Parents	Form and Instruction	New	Repair queued
Form 0920-1154 Consent Form - Parent Participant	Form and Instruction	New	Repair queued
Form 0920-1154 Focus Group Recruitment Materials - Parents	Form and Instruction	New	Repair queued
Form 0920-1154 Recruitment Screener	Form and Instruction	New	Repair queued
Form 0920-1154 Virtual Focus Group Guide	Form and Instruction	New	Repair queued
Form 0920-1154 Conversation Guide for Social Service Providers	Form and Instruction	New	Repair queued
Form 0920-1154 Conversation Guide for Parents and Young Adults	Form and Instruction	New	Repair queued
Safety Skills at Work Post-Training Feedback Session Questions	Form and Instruction	New	Repair queued
Safety Skills at Work Follow-up Survey	Form and Instruction	New	Repair queued
Safety Skills at Work Post-Survey	Form and Instruction	New	Repair queued
Safety Skills at Work Pre-Survey	Form and Instruction	New	Repair queued
Form 0920-22HH AttD - Exercise Evaluation Form and Guide - CYSHCN TTX	Form and Instruction	New	Repair queued
Form 0920-22HH Att C Tabletop Exercise CYSHCN Feedback Form	Form and Instruction	New	Repair queued
Form 0920-22HH Att B Tabletop Exercise Question Bank and Guide (for Moderators)	Form and Instruction	New	Repair queued
Form 0920-1154 Moderators Guide for Rural Participants	Form and Instruction	New	Repair queued
Form 0920-1154 Screener Rural Participants	Form and Instruction	New	Repair queued
Form 0920-1154 Moderators Guide for African Americans	Form and Instruction	New	Repair queued
Form 0920-1154 Screener African Americans	Form and Instruction	New	Repair queued
Form 0920-1154 Moderators Guide for Young People	Form and Instruction	New	Repair queued
Form 0920-1154 Information Sheet for Young People	Form and Instruction	New	Repair queued
Form 0920-1154 Screener Parents of Young People	Form and Instruction	New	Repair queued
Form 0920-1154 Parent Consent Form	Form and Instruction	New	Repair queued
Form 0920-1154 Interview Guide	Form and Instruction	New	Repair queued
Form 0920-1154 Youth Recruitment Screener Questionnaire	Form and Instruction	New	Repair queued
Form 0920-1154 Young Adult Recruitment Screener Questionnaire	Form and Instruction	New	Repair queued
Form 0920-1154 Parent/Guardian Email and Youth Informed Assent	Form and Instruction	New	Repair queued
Form 0920-1154 Young Adult Informed Consent	Form and Instruction	New	Repair queued
Form 0920-1154 Parent/Guardian Email and Informed Consent	Form and Instruction	New	Repair queued
Form 0920-1154 Parent/Guardian Email and Informed Consent	Form and Instruction	New	Repair queued
Form 0920-1154 NIOSH Study Evaluation Survey	Form and Instruction	New	Repair queued
Form 0920-22EM Federal Select Agent Program Feedback Survey	Form and Instruction	New	Repair queued
Form 0920-1154 Survey Questionnaire	Form and Instruction	New	Repair queued
Substance Use Prevention Practitioner Focus Group Discussion Guide	Form and Instruction	New	Repair queued
Bullying Prevention Practitioner Focus Group Discussion Guide	Form and Instruction	New	Repair queued
Parent and Caregiver Focus Group Discussion Guide	Form and Instruction	New	Repair queued
Recruitment Emails for Practitioners	Form and Instruction	New	Repair queued
Screener for Parents and Caregivers	Form and Instruction	New	Repair queued
Form 0920-1154 Respondent Technology Screener	Form and Instruction	New	Repair queued
Form 0920-1154 Focus Group Moderator Guide - Pregnant	Form and Instruction	New	Repair queued
Form 0920-1154 Focus Group Moderator Guide - Parents	Form and Instruction	New	Repair queued
Form 0920-1154 Focus Group Moderator Guide - General	Form and Instruction	New	Repair queued
Form 0920-1154 Eligibility and Demographic Screener	Form and Instruction	New	Repair queued
Form 0920-1154 Focus Group Discussion Guide and Consent	Form and Instruction	New	Repair queued
Form 0920-1154 Screening Form	Form and Instruction	New	Repair queued
Form 0920-1154 ArboNET Needs Assessment	Form	New	Repair queued
Focus Group Guide (script) for Workers	Form and Instruction	New	Repair queued
Focus Group Guide (script) for Stakeholders	Form and Instruction	New	Repair queued
Form 0920-1255 Interview Guide	Form and Instruction	New	Repair queued
Form 0920-1255 IM Team Survey	Form and Instruction	New	Repair queued
Form 0920-1255 Peer Assessor Protocol	Form and Instruction	New	Repair queued
Form 0920-1255 Incident Background Information	Form and Instruction	New	Repair queued
Form 0920-1154 Training for Employers Post-Test	Form	New	Repair queued
Form 0920-1154 Training for Employers Pre-Test	Form	New	Repair queued
Form 0920-21EY Team Trainers Survery	Form and Instruction	New	Repair queued
Form 0920-21EY VRMine_Attachment_C_Briefing Officer Survey	Form and Instruction	New	Repair queued
Form 0920-21EY VRMine_Attachment_B_Exploration Team Survey	Form and Instruction	New	Repair queued
Form 0920-1154 Irradiation and Food Safety	Form	New	Repair queued
Form 0920-1154 Moderator's Guide for Focus Group Set 2	Form and Instruction	New	Repair queued
Form 0920-1154 Moderator's Guide for Focus Group	Form and Instruction	New	Repair queued
Form 0920-1154 Screening Instrument for Focus Groups	Form	New	Repair queued
Screener	Form	New	Repair queued
Form 0920-1154 Interview Moderator Guide	Form and Instruction	New	Repair queued
Form 0920-1154 Screener	Form	New	Repair queued
Survey	Form and Instruction	New	Available
Screener	Form and Instruction	New	Available
Interview Guide	Form and Instruction	New	Repair queued
Screener	Form and Instruction	New	Repair queued
Team Trainer Interview Questions	Form and Instruction	New	Available
Briefing Officer Survey	Form and Instruction	New	Available
Exploration Team Survey	Form and Instruction	New	Available
School District Feedback Form	Form	New	Available
Webinar Feedback Form	Form	New	Available
Pilot Site Baseline Survey	Form	New	Available
Demographic Data Collection Points	Form	New	Available
Electronic Platform Chronic Absenteeism Reporting Form	Form	New	Available
Cognitive Interview Guide	Form and Instruction	New	Repair queued
Semi-structured Interview Guide	Form and Instruction	New	Repair queued
Screening Questions	Form and Instruction	New	Repair queued
Form 0920-20MD Attachment A13_Attending Physician_Overall Program Evaluation	Form and Instruction	New	Available
Form 0920-20MD Attachment A12_Resident_Overall Program Evaluation	Form and Instruction	New	Available
Form 0920-20MD Attachment A11_Resident_Overall Effects & Prevalence video post test	Form and Instruction	New	Available
Form 0920-20MD Attachment A10_Resident_Overall Effects & Prevalence video pretest	Form and Instruction	New	Available
Form 0920-20MD Attachment A9_Attending Physicians_Training Program Evaluation	Form and Instruction	New	Available
Form 0920-20MD Attachment A7_Attending Physicians_Educational Care pretest	Form and Instruction	New	Available
Form 0920-20MD Attachment A6_Attending Physicians_Overcoming Social Attitudes post test	Form and Instruction	New	Available
Form 0920-20MD Attachment A5_Attending Physicians_Overcoming Social Attitudes pretest	Form and Instruction	New	Available
Form 0920-20MD Attachment A4_Attending Physicians_Treatment Across Lifespan post test	Form and Instruction	New	Available
Form 0920-20MD Attachment A3_Attending Physicians_Treatment Across Lifespan pretest	Form and Instruction	New	Available
Form 0920-20MD Attachment A2_Attending Physicians_Screening & Diagnosis post test	Form and Instruction	New	Available
Form 0920-20MD Attachment A1_Attending Physicians_Screening & Diagnosis pretest	Form and Instruction	New	Available
Form 0920-1154 Pediatrician - ECHO Debriefing Conference Call	Form and Instruction	New	Available
Form 0920-1154 Pediatrician - ECHO Program Satisfaction Survey	Form and Instruction	New	Available
Form 0920-1154 Pediatrician - ECHO Session Satisfaction Survey	Form and Instruction	New	Available
Form 0920-1154 Peditrician - ECHO Chart Review	Form and Instruction	New	Available
Form 0920-1154 Interview Guide	Form and Instruction	New	Available
Form 0920-1154 DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL -- revised	Form and Instruction	New	Available
Form 0920-1154 DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL -- revised	Form and Instruction	New	Available
Form 0920-1154 INTERVIEW GUIDE FOR BRIEF FAMILY INTERVIEW	Form	New	Available
Form 0920-1154 DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL	Form and Instruction	New	Available
Form 0920-1154 DREXEL -DEMOGRAPHIC INTAKE FORM	Form	New	Available
Form 0920-20IU Critical Decision Method (CDM) Semi-Structured Interview Guide	Form and Instruction	New	Available
Form 0920-20IU Cognitive Task Analysis (CTA) Interview Guide	Form and Instruction	New	Available
Form 0920-20LK NIOSH Toolbox Focus Group Guide	Form and Instruction	New	Available
Form 0920-1154 Interview Guide	Form and Instruction	New	Available
GenICRequestTemplate.docx	Supplementary Document	Uploaded 2019-12-05	Available
60 day FRN.pdf	Supplementary Document	Uploaded 2019-12-05	Available
SSB.docx	Supporting Statement B	Uploaded 2019-12-05	Available
SSA.2019.doc	Supporting Statement A	Uploaded 2019-12-05	Available
AuthLegislation.doc	Supplementary Document	Uploaded 2016-10-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
257952	[NCIPC] HEADS UO Outreach to At Risks Groups--Formative Testing	Form and Instruction	New	Focus Group Guide: Youth
257952	[NCIPC] HEADS UO Outreach to At Risks Groups--Formative Testing	Form and Instruction	New	Consent Form - Parent of Youth Participant
257952	[NCIPC] HEADS UO Outreach to At Risks Groups--Formative Testing	Form and Instruction	New	Focus Group Recruitment Materials - Youth
257952	[NCIPC] HEADS UO Outreach to At Risks Groups--Formative Testing	Form and Instruction	New	Focus Group Guide: Parents
257952	[NCIPC] HEADS UO Outreach to At Risks Groups--Formative Testing	Form and Instruction	New	Consent Form - Parent Participant
257952	[NCIPC] HEADS UO Outreach to At Risks Groups--Formative Testing	Form and Instruction	New	Focus Group Recruitment Materials - Parents
257952	[NCIPC] HEADS UO Outreach to At Risks Groups--Formative Testing	Instruction	New
254776	Mapping experiences of young adults and families impacted by adverse childhood experiences (ACEs)	Form and Instruction	New	Recruitment Screener
254776	Mapping experiences of young adults and families impacted by adverse childhood experiences (ACEs)	Form and Instruction	New	Virtual Focus Group Guide
254776	Mapping experiences of young adults and families impacted by adverse childhood experiences (ACEs)	Form and Instruction	New	Conversation Guide for Social Service Providers
254776	Mapping experiences of young adults and families impacted by adverse childhood experiences (ACEs)	Form and Instruction	New	Conversation Guide for Parents and Young Adults
254776	Mapping experiences of young adults and families impacted by adverse childhood experiences (ACEs)	Instruction	New
254736	[2022, NIOSH] Formative Research and Field Pilot Evaluation to Inform the Development of a NIOSH Training Product, the Safety Skills at Work Curriculum	Form and Instruction	New	Safety Skills at Work Post-Training Feedback Session Questions
254736	[2022, NIOSH] Formative Research and Field Pilot Evaluation to Inform the Development of a NIOSH Training Product, the Safety Skills at Work Curriculum	Form and Instruction	New	Safety Skills at Work Follow-up Survey
254736	[2022, NIOSH] Formative Research and Field Pilot Evaluation to Inform the Development of a NIOSH Training Product, the Safety Skills at Work Curriculum	Form and Instruction	New	Safety Skills at Work Post-Survey
254736	[2022, NIOSH] Formative Research and Field Pilot Evaluation to Inform the Development of a NIOSH Training Product, the Safety Skills at Work Curriculum	Form and Instruction	New	Safety Skills at Work Pre-Survey
254714	Tabletop Exercise-- Home Assessments for Patients and Families with Special Health Care Needs Developing Tools, Communication Strategies, and Standards	Form and Instruction	New	AttD - Exercise Evaluation Form and Guide - CYSHCN TTX
254714	Tabletop Exercise-- Home Assessments for Patients and Families with Special Health Care Needs Developing Tools, Communication Strategies, and Standards	Form and Instruction	New	Att C Tabletop Exercise CYSHCN Feedback Form
254714	Tabletop Exercise-- Home Assessments for Patients and Families with Special Health Care Needs Developing Tools, Communication Strategies, and Standards	Form and Instruction	New	Att B Tabletop Exercise Question Bank and Guide (for Moderators)
254432	Drug Overdose Prevention Information Needs Among African Americans, People Living in Rural Areas, and Young People Ages 12-17 Years Old	Form and Instruction	New	Moderators Guide for Rural Participants
254432	Drug Overdose Prevention Information Needs Among African Americans, People Living in Rural Areas, and Young People Ages 12-17 Years Old	Form and Instruction	New	Screener Rural Participants
254432	Drug Overdose Prevention Information Needs Among African Americans, People Living in Rural Areas, and Young People Ages 12-17 Years Old	Form and Instruction	New	Moderators Guide for African Americans
254432	Drug Overdose Prevention Information Needs Among African Americans, People Living in Rural Areas, and Young People Ages 12-17 Years Old	Form and Instruction	New	Screener African Americans
254432	Drug Overdose Prevention Information Needs Among African Americans, People Living in Rural Areas, and Young People Ages 12-17 Years Old	Form and Instruction	New	Moderators Guide for Young People
254432	Drug Overdose Prevention Information Needs Among African Americans, People Living in Rural Areas, and Young People Ages 12-17 Years Old	Form and Instruction	New	Information Sheet for Young People
254432	Drug Overdose Prevention Information Needs Among African Americans, People Living in Rural Areas, and Young People Ages 12-17 Years Old	Form and Instruction	New	Screener Parents of Young People
254432	Drug Overdose Prevention Information Needs Among African Americans, People Living in Rural Areas, and Young People Ages 12-17 Years Old	Form and Instruction	New	Parent Consent Form
254430	Youth and Young Adult Formative In-Depth Interviews on Health Equity and Tobacco Use	Form and Instruction	New	Interview Guide
254430	Youth and Young Adult Formative In-Depth Interviews on Health Equity and Tobacco Use	Form and Instruction	New	Youth Recruitment Screener Questionnaire
254430	Youth and Young Adult Formative In-Depth Interviews on Health Equity and Tobacco Use	Form and Instruction	New	Young Adult Recruitment Screener Questionnaire
254430	Youth and Young Adult Formative In-Depth Interviews on Health Equity and Tobacco Use	Form and Instruction	New	Parent/Guardian Email and Youth Informed Assent
254430	Youth and Young Adult Formative In-Depth Interviews on Health Equity and Tobacco Use	Form and Instruction	New	Young Adult Informed Consent
254430	Youth and Young Adult Formative In-Depth Interviews on Health Equity and Tobacco Use	Form and Instruction	New	Parent/Guardian Email and Informed Consent
254430	Youth and Young Adult Formative In-Depth Interviews on Health Equity and Tobacco Use	Form and Instruction	New	Parent/Guardian Email and Informed Consent
253262	Field Testing of an Instrument to Assess the Uptake and Reach	Form and Instruction	New	NIOSH Study Evaluation Survey
253034	Federal Select Agent Program Feedback Survey	Form and Instruction	New	Federal Select Agent Program Feedback Survey
253016	Integrating Comprehensive Family-Centered Care into Substance Use Treatment Programs for Pregnant and Postpartum Women to Prevent the Intergenerational Transmission of Adverse Childhood Experiences	Form and Instruction	New	Survey Questionnaire
252456	Connecting the Dots Across Injury Prevention Bullying and Substance Use Prevention Message Testing	Form and Instruction	New	Substance Use Prevention Practitioner Focus Group Discussion Guide
252456	Connecting the Dots Across Injury Prevention Bullying and Substance Use Prevention Message Testing	Form and Instruction	New	Bullying Prevention Practitioner Focus Group Discussion Guide
252456	Connecting the Dots Across Injury Prevention Bullying and Substance Use Prevention Message Testing	Form and Instruction	New	Parent and Caregiver Focus Group Discussion Guide
252456	Connecting the Dots Across Injury Prevention Bullying and Substance Use Prevention Message Testing	Form and Instruction	New	Recruitment Emails for Practitioners
252456	Connecting the Dots Across Injury Prevention Bullying and Substance Use Prevention Message Testing	Form and Instruction	New	Screener for Parents and Caregivers
251914	Food Safety Communication Evaluation: Focus Groups Assessing Food Safety Messages, Knowledge, and Attitudes	Form and Instruction	New	Respondent Technology Screener
251914	Food Safety Communication Evaluation: Focus Groups Assessing Food Safety Messages, Knowledge, and Attitudes	Form and Instruction	New	Focus Group Moderator Guide - Pregnant
251914	Food Safety Communication Evaluation: Focus Groups Assessing Food Safety Messages, Knowledge, and Attitudes	Form and Instruction	New	Focus Group Moderator Guide - Parents
251914	Food Safety Communication Evaluation: Focus Groups Assessing Food Safety Messages, Knowledge, and Attitudes	Form and Instruction	New	Focus Group Moderator Guide - General
251914	Food Safety Communication Evaluation: Focus Groups Assessing Food Safety Messages, Knowledge, and Attitudes	Form and Instruction	New	Eligibility and Demographic Screener
251447	HEADS UP! Parents Feedback	Form and Instruction	New	Focus Group Discussion Guide and Consent
251447	HEADS UP! Parents Feedback	Form and Instruction	New	Screening Form
251447	HEADS UP! Parents Feedback	Other-Recruitment Materials	New
251388	ArboNET Needs Assessment	Form	New	ArboNET Needs Assessment
251012	Farm to Table: Knowledge Base Preventing Musculoskeletal Disorders Among Food and Beverage Workers	Form and Instruction	New	Focus Group Guide (script) for Workers
251012	Farm to Table: Knowledge Base Preventing Musculoskeletal Disorders Among Food and Beverage Workers	Form and Instruction	New	Focus Group Guide (script) for Stakeholders
250974	Strengthening Public Health Incident Management Through Continuous Quality Improvement	Form and Instruction	New	Interview Guide
250974	Strengthening Public Health Incident Management Through Continuous Quality Improvement	Form and Instruction	New	IM Team Survey
250974	Strengthening Public Health Incident Management Through Continuous Quality Improvement	Form and Instruction	New	Peer Assessor Protocol
250974	Strengthening Public Health Incident Management Through Continuous Quality Improvement	Form and Instruction	New	Incident Background Information
249664	Pre/Post Draft Heat Stress Focus Group/Training with Outdoor Workers	Form	New	Training for Employers Post-Test
249664	Pre/Post Draft Heat Stress Focus Group/Training with Outdoor Workers	Form	New	Training for Employers Pre-Test
249664	Pre/Post Draft Heat Stress Focus Group/Training with Outdoor Workers	Other-Paper	New
249357	Seat belt use among workers who drive as part of their job: what's not "clicking"?	Other-WORD	New
248275	Customer Discovery Interviews with Small Outdoor Service Businesses	Other-WORD	New
247214	Formative Evaluation of an Immersive VRMine Rescue Contest Simulation Exercise	Form and Instruction	New	Team Trainers Survery
247214	Formative Evaluation of an Immersive VRMine Rescue Contest Simulation Exercise	Form and Instruction	New	VRMine_Attachment_C_Briefing Officer Survey
247214	Formative Evaluation of an Immersive VRMine Rescue Contest Simulation Exercise	Form and Instruction	New	VRMine_Attachment_B_Exploration Team Survey
245850	Focus Group Study of U.S. Adults' Knowledge and Attitudes of Irradiation as a Food Safety Intervention	Form	New	Irradiation and Food Safety
245850	Focus Group Study of U.S. Adults' Knowledge and Attitudes of Irradiation as a Food Safety Intervention	Form and Instruction	New	Moderator's Guide for Focus Group Set 2
245850	Focus Group Study of U.S. Adults' Knowledge and Attitudes of Irradiation as a Food Safety Intervention	Form and Instruction	New	Moderator's Guide for Focus Group
245850	Focus Group Study of U.S. Adults' Knowledge and Attitudes of Irradiation as a Food Safety Intervention	Form	New	Screening Instrument for Focus Groups
245720	Focus Group Study of U.S. Adult's Knowledge and Attitudes for Salmonella Infections and Keeping Backyard Poultry	Form	New	Screener
245720	Focus Group Study of U.S. Adult's Knowledge and Attitudes for Salmonella Infections and Keeping Backyard Poultry	Other-Focus group guide	New
245719	Determining Barriers to Hearing Conservation Program Success through Worker Interviews	Other-Interview guide	New
245197	Use of Hand Sanitizer Among U.S. Adults: A Formative Qualitative Evaluation	Form and Instruction	New	Interview Moderator Guide
245197	Use of Hand Sanitizer Among U.S. Adults: A Formative Qualitative Evaluation	Form	New	Screener
244720	Health Education and Health Promotion in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Knowledge, Attitudes and Beliefs in the U.S. General Public	Form and Instruction	New	Survey
244720	Health Education and Health Promotion in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Knowledge, Attitudes and Beliefs in the U.S. General Public	Form and Instruction	New	Screener
244592	Knowledge, Attitudes, and Perceptions of Shigellosis Related Prevention Behaviors Among Men Who Have Sex With Men	Form and Instruction	New	Interview Guide
244592	Knowledge, Attitudes, and Perceptions of Shigellosis Related Prevention Behaviors Among Men Who Have Sex With Men	Form and Instruction	New	Screener
244188	Formative Evaluation of an Immersive VRMine Rescue Contest Simulation Exercise	Form and Instruction	New	Team Trainer Interview Questions
244188	Formative Evaluation of an Immersive VRMine Rescue Contest Simulation Exercise	Form and Instruction	New	Briefing Officer Survey
244188	Formative Evaluation of an Immersive VRMine Rescue Contest Simulation Exercise	Form and Instruction	New	Exploration Team Survey
243850	Formative Research to Support Active Surveillance of Myalgic Encelphalomyelitis/Chronic Fatigue Syndrome Among Schoolchildren	Form	New	School District Feedback Form
243850	Formative Research to Support Active Surveillance of Myalgic Encelphalomyelitis/Chronic Fatigue Syndrome Among Schoolchildren	Form	New	Webinar Feedback Form
243850	Formative Research to Support Active Surveillance of Myalgic Encelphalomyelitis/Chronic Fatigue Syndrome Among Schoolchildren	Form	New	Pilot Site Baseline Survey
243850	Formative Research to Support Active Surveillance of Myalgic Encelphalomyelitis/Chronic Fatigue Syndrome Among Schoolchildren	Form	New	Demographic Data Collection Points
243850	Formative Research to Support Active Surveillance of Myalgic Encelphalomyelitis/Chronic Fatigue Syndrome Among Schoolchildren	Form	New	Electronic Platform Chronic Absenteeism Reporting Form
243850	Formative Research to Support Active Surveillance of Myalgic Encelphalomyelitis/Chronic Fatigue Syndrome Among Schoolchildren	Other-Question Guide	New
243553	(genIC) Feedback Survey for Community Counts Data Viz Tool	Other-Screenshots	New
243249	Tool Development for the Assessment of Uptake and Reach of NIOSH Exposure Assessment Research	Form and Instruction	New	Cognitive Interview Guide
243249	Tool Development for the Assessment of Uptake and Reach of NIOSH Exposure Assessment Research	Form and Instruction	New	Semi-structured Interview Guide
243249	Tool Development for the Assessment of Uptake and Reach of NIOSH Exposure Assessment Research	Form and Instruction	New	Screening Questions
242950	American Academy of Pediatrics Resident Training in Developmental Continuity Clinics (part 3)	Form and Instruction	New	Attachment A13_Attending Physician_Overall Program Evaluation
242950	American Academy of Pediatrics Resident Training in Developmental Continuity Clinics (part 3)	Form and Instruction	New	Attachment A12_Resident_Overall Program Evaluation
242950	American Academy of Pediatrics Resident Training in Developmental Continuity Clinics (part 3)	Form and Instruction	New	Attachment A11_Resident_Overall Effects & Prevalence video post test
242950	American Academy of Pediatrics Resident Training in Developmental Continuity Clinics (part 3)	Form and Instruction	New	Attachment A10_Resident_Overall Effects & Prevalence video pretest
242950	American Academy of Pediatrics Resident Training in Developmental Continuity Clinics (part 3)	Form and Instruction	New	Attachment A9_Attending Physicians_Training Program Evaluation
242950	American Academy of Pediatrics Resident Training in Developmental Continuity Clinics (part 3)	Form and Instruction	New	Attachment A7_Attending Physicians_Educational Care pretest
242950	American Academy of Pediatrics Resident Training in Developmental Continuity Clinics (part 3)	Form and Instruction	New	Attachment A6_Attending Physicians_Overcoming Social Attitudes post test
242950	American Academy of Pediatrics Resident Training in Developmental Continuity Clinics (part 3)	Form and Instruction	New	Attachment A5_Attending Physicians_Overcoming Social Attitudes pretest
242950	American Academy of Pediatrics Resident Training in Developmental Continuity Clinics (part 3)	Form and Instruction	New	Attachment A4_Attending Physicians_Treatment Across Lifespan post test
242950	American Academy of Pediatrics Resident Training in Developmental Continuity Clinics (part 3)	Form and Instruction	New	Attachment A3_Attending Physicians_Treatment Across Lifespan pretest
242950	American Academy of Pediatrics Resident Training in Developmental Continuity Clinics (part 3)	Form and Instruction	New	Attachment A2_Attending Physicians_Screening & Diagnosis post test
242950	American Academy of Pediatrics Resident Training in Developmental Continuity Clinics (part 3)	Form and Instruction	New	Attachment A1_Attending Physicians_Screening & Diagnosis pretest
242188	American Academy of Pediatrics Neurodevelopmental (ECHO)	Form and Instruction	New	Pediatrician - ECHO Debriefing Conference Call
242188	American Academy of Pediatrics Neurodevelopmental (ECHO)	Form and Instruction	New	Pediatrician - ECHO Program Satisfaction Survey
242188	American Academy of Pediatrics Neurodevelopmental (ECHO)	Form and Instruction	New	Pediatrician - ECHO Session Satisfaction Survey
242188	American Academy of Pediatrics Neurodevelopmental (ECHO)	Form and Instruction	New	Peditrician - ECHO Chart Review
241652	Formative Research and Tool Development - "Strengthening hospital-based youth violence prevention	Form and Instruction	New	Interview Guide
241328	DREXEL-CYSHCN	Form and Instruction	New	DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL -- revised
241328	DREXEL-CYSHCN	Form and Instruction	New	DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL -- revised
241328	DREXEL-CYSHCN	Form	New	INTERVIEW GUIDE FOR BRIEF FAMILY INTERVIEW
241328	DREXEL-CYSHCN	Form and Instruction	New	DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL
241328	DREXEL-CYSHCN	Form	New	DREXEL -DEMOGRAPHIC INTAKE FORM
241328	DREXEL-CYSHCN	Instruction	New
241323	Characterization of Haul Truck Health and Safety Issues	Form and Instruction	New	Critical Decision Method (CDM) Semi-Structured Interview Guide
241323	Characterization of Haul Truck Health and Safety Issues	Form and Instruction	New	Cognitive Task Analysis (CTA) Interview Guide
241061	Formative Assessment of the Information Needs of Adapting NIOSH-CPWR toolbox talks for Spanish-speaking construction workers: Phase 1	Form and Instruction	New	NIOSH Toolbox Focus Group Guide
239851	Strengthening hospital-based youth violence prevention	Form and Instruction	New	Interview Guide

ICR Details

OMB Control No: 0920-1154	ICR Reference No: 201912-0920-003
Status: Historical Active	Previous ICR Reference No: 201610-0920-009
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1154
Title: CDC/ATSDR Formative Research and Tool Development
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/21/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/23/2019
Terms of Clearance: Previous terms continue: OMB approves this umbrella generic, and has informed CDC/ATSDR that each individual study should be submitted into ROCIS an a genIC that includes full supporting statement Part A and an accompanying Supporting Statement Part B if any statistical methods are employed for sampling or analyses of data. A complete justification for any incentives offered to respondents will also accompany all substudies submitted under this Generic. Outcomes collected under this generic pathway are intended for internal CDC/ATSDR use only and will not be generalized beyond the scope of each study or to broader populations.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2023	36 Months From Approved	01/31/2020
Responses	75,000	0	60,000
Time Burden (Hours)	60,000	0	56,250
Cost Burden (Dollars)	1,500,000	0	1,125,000

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Abstract: CDC/ATSDR requests an extension of a generic clearance to conduct formative research for developing new tools and methodologies to support agency research, surveillance, and program evaluation activities, and the development and assessment of multi-use tools.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: PHSA
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 44308	08/23/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 66909	12/06/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 36

table that charts list of burden

IC Title	Form No.	Form Name
(genIC) Feedback Survey for Community Counts Data Viz Tool
American Academy of Pediatrics Neurodevelopmental (ECHO)	0920-1154, 0920-1154, 0920-1154, 0920-1154	Peditrician - ECHO Chart Review ,   Pediatrician - ECHO Session Satisfaction Survey ,   Pediatrician - ECHO Program Satisfaction Survey ,   Pediatrician - ECHO Debriefing Conference Call
American Academy of Pediatrics Resident Training in Developmental Continuity Clinics (part 3)	0920-20MD, 0920-20MD, 0920-20MD, 0920-20MD, 0920-20MD, 0920-20MD, 0920-20MD, 0920-20MD, 0920-20MD, 0920-20MD, 0920-20MD, 0920-20MD	Attachment A1_Attending Physicians_Screening & Diagnosis pretest ,   Attachment A2_Attending Physicians_Screening & Diagnosis post test ,   Attachment A3_Attending Physicians_Treatment Across Lifespan pretest ,   Attachment A4_Attending Physicians_Treatment Across Lifespan post test ,   Attachment A5_Attending Physicians_Overcoming Social Attitudes pretest ,   Attachment A6_Attending Physicians_Overcoming Social Attitudes post test ,   Attachment A7_Attending Physicians_Educational Care pretest ,   Attachment A9_Attending Physicians_Training Program Evaluation ,   Attachment A10_Resident_Overall Effects & Prevalence video pretest ,   Attachment A11_Resident_Overall Effects & Prevalence video post test ,   Attachment A12_Resident_Overall Program Evaluation ,   Attachment A13_Attending Physician_Overall Program Evaluation
ArboNET Needs Assessment	0920-1154	ArboNET Needs Assessment
Characterization of Haul Truck Health and Safety Issues	0920-20IU, 0920-20IU	Cognitive Task Analysis (CTA) Interview Guide ,   Critical Decision Method (CDM) Semi-Structured Interview Guide
Connecting the Dots Across Injury Prevention Bullying and Substance Use Prevention Message Testing 	None, None, None, None, None	Screener for Parents and Caregivers ,   Recruitment Emails for Practitioners ,   Parent and Caregiver Focus Group Discussion Guide ,   Bullying Prevention Practitioner Focus Group Discussion Guide ,   Substance Use Prevention Practitioner Focus Group Discussion Guide
Customer Discovery Interviews with Small Outdoor Service Businesses
DREXEL-CYSHCN	0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154	DREXEL -DEMOGRAPHIC INTAKE FORM ,   DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL ,   INTERVIEW GUIDE FOR BRIEF FAMILY INTERVIEW ,   DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL -- revised ,   DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL -- revised
Determining Barriers to Hearing Conservation Program Success through Worker Interviews
Drug Overdose Prevention Information Needs Among African Americans, People Living in Rural Areas, and Young People Ages 12-17 Years Old	0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154	Parent Consent Form ,   Screener Parents of Young People ,   Information Sheet for Young People ,   Moderators Guide for Young People ,   Screener African Americans ,   Moderators Guide for African Americans ,   Screener Rural Participants ,   Moderators Guide for Rural Participants
Farm to Table: Knowledge Base Preventing Musculoskeletal Disorders Among Food and Beverage Workers	n/a, n/a	Focus Group Guide (script) for Stakeholders ,   Focus Group Guide (script) for Workers
Federal Select Agent Program Feedback Survey	0920-22EM	Federal Select Agent Program Feedback Survey
Field Testing of an Instrument to Assess the Uptake and Reach	0920-1154	NIOSH Study Evaluation Survey
Focus Group Study of U.S. Adult's Knowledge and Attitudes for Salmonella Infections and Keeping Backyard Poultry	none	Screener
Focus Group Study of U.S. Adults' Knowledge and Attitudes of Irradiation as a Food Safety Intervention	0920-1154, 0920-1154, 0920-1154, 0920-1154	Screening Instrument for Focus Groups ,   Moderator's Guide for Focus Group ,   Moderator's Guide for Focus Group Set 2 ,   Irradiation and Food Safety
Food Safety Communication Evaluation: Focus Groups Assessing Food Safety Messages, Knowledge, and Attitudes	0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154	Eligibility and Demographic Screener ,   Focus Group Moderator Guide - General ,   Focus Group Moderator Guide - Parents ,   Focus Group Moderator Guide - Pregnant ,   Respondent Technology Screener
Formative Assessment of the Information Needs of Adapting NIOSH-CPWR toolbox talks for Spanish-speaking construction workers: Phase 1	0920-20LK	NIOSH Toolbox Focus Group Guide
Formative Evaluation of an Immersive VRMine Rescue Contest Simulation Exercise	0920-21EY, 0920-21EY, 0920-21EY	VRMine_Attachment_B_Exploration Team Survey ,   VRMine_Attachment_C_Briefing Officer Survey ,   Team Trainers Survery
Formative Evaluation of an Immersive VRMine Rescue Contest Simulation Exercise	n/a, n/a, n/a	Exploration Team Survey ,   Briefing Officer Survey ,   Team Trainer Interview Questions
Formative Research and Tool Development - "Strengthening hospital-based youth violence prevention	0920-1154	Interview Guide
Formative Research to Support Active Surveillance of Myalgic Encelphalomyelitis/Chronic Fatigue Syndrome Among Schoolchildren	none, none, none, none, none	Electronic Platform Chronic Absenteeism Reporting Form ,   Demographic Data Collection Points ,   Pilot Site Baseline Survey ,   Webinar Feedback Form ,   School District Feedback Form
HEADS UP! Parents Feedback	0920-1154, 0920-1154	Screening Form ,   Focus Group Discussion Guide and Consent
Health Education and Health Promotion in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Knowledge, Attitudes and Beliefs in the U.S. General Public	n/a, n/a	Screener ,   Survey
Integrating Comprehensive Family-Centered Care into Substance Use Treatment Programs for Pregnant and Postpartum Women to Prevent the Intergenerational Transmission of Adverse Childhood Experiences	0920-1154	Survey Questionnaire
Knowledge, Attitudes, and Perceptions of Shigellosis Related Prevention Behaviors Among Men Who Have Sex With Men	n/a, n/a	Screener ,   Interview Guide
Mapping experiences of young adults and families impacted by adverse childhood experiences (ACEs)	0920-1154, 0920-1154, 0920-1154, 0920-1154	Conversation Guide for Parents and Young Adults ,   Conversation Guide for Social Service Providers ,   Virtual Focus Group Guide ,   Recruitment Screener
Pre/Post Draft Heat Stress Focus Group/Training with Outdoor Workers	0920-1154, 0920-1154	Training for Employers Pre-Test ,   Training for Employers Post-Test
Seat belt use among workers who drive as part of their job: what's not "clicking"?
Strengthening Public Health Incident Management Through Continuous Quality Improvement	0920-1255, 0920-1255, 0920-1255, 0920-1255	Incident Background Information ,   Peer Assessor Protocol ,   IM Team Survey ,   Interview Guide
Strengthening hospital-based youth violence prevention	0920-1154	Interview Guide
Tabletop Exercise-- Home Assessments for Patients and Families with Special Health Care Needs Developing Tools, Communication Strategies, and Standards	0920-22HH, 0920-22HH, 0920-22HH	Att B Tabletop Exercise Question Bank and Guide (for Moderators) ,   Att C Tabletop Exercise CYSHCN Feedback Form ,   AttD - Exercise Evaluation Form and Guide - CYSHCN TTX
Tool Development for the Assessment of Uptake and Reach of NIOSH Exposure Assessment Research	n/a, n/a, n/a	Screening Questions ,   Semi-structured Interview Guide ,   Cognitive Interview Guide
Use of Hand Sanitizer Among U.S. Adults: A Formative Qualitative Evaluation	0920-1154, 0920-1154	Screener ,   Interview Moderator Guide
Youth and Young Adult Formative In-Depth Interviews on Health Equity and Tobacco Use	0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154	Parent/Guardian Email and Informed Consent ,   Parent/Guardian Email and Informed Consent ,   Young Adult Informed Consent ,   Parent/Guardian Email and Youth Informed Assent ,   Young Adult Recruitment Screener Questionnaire ,   Youth Recruitment Screener Questionnaire ,   Interview Guide
[2022, NIOSH] Formative Research and Field Pilot Evaluation to Inform the Development of a NIOSH Training Product, the Safety Skills at Work Curriculum	None, None, None, None	Safety Skills at Work Pre-Survey ,   Safety Skills at Work Post-Survey ,   Safety Skills at Work Follow-up Survey ,   Safety Skills at Work Post-Training Feedback Session Questions
[NCIPC] HEADS UO Outreach to At Risks Groups--Formative Testing	0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154, 0920-1154	Focus Group Recruitment Materials - Parents ,   Consent Form - Parent Participant ,   Focus Group Guide: Parents ,   Focus Group Recruitment Materials - Youth ,   Consent Form - Parent of Youth Participant ,   Focus Group Guide: Youth

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	75,000	60,000	0	15,000	0	0
Annual Time Burden (Hours)	60,000	56,250	0	3,750	0	0
Annual Cost Burden (Dollars)	1,500,000	1,125,000	0	375,000	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This extension request includes an increase in burden due to increased use of the generic over the past 3 years.

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Annual Cost to Federal Government: $474,091

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/23/2019

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