GENIC Template with Project Description

Request for genIC Approval

CDC/ATSDR Formative Research and Tool Development

0920-1154

CIO: NCEZID

PROJECT TITLE: Health Education and Health Promotion in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Knowledge, Attitudes and Beliefs (KAB) in the U.S. General Public

PURPOSE AND USE OF COLLECTION:

The purpose of this KAB pilot project is to 1) develop an assessment tool for measuring perceptions and KABs of ME/CFS in the general public, 2) use the results to refine the developed assessment tool of KABs and inform strategic planning for health education and health promotion future educational activities. This pilot project will assess perceptions and KABs about ME/CFS, and ME/CFS symptoms and diagnosis from the general public in the United States. The KAB information will help identify information among the demographic subpopulations of the general public needed to formulate strategic planning for future stakeholder engagement activities and inform the development of future educational materials and assessments. For example, findings on KABs across demographic subgroups will be used to identify gaps in health education and health promotion of KABs that can be addressed in future educational and stakeholder engagement activities.

DESCRIPTION OF RESPONDENTS:

Members of the general public that visit and navigate the WebMD website for health information will be randomly selected to participate in the web-based KAB pilot project.

An invitation “pop-up” box will be displayed on the web visitor’s screen. The invitation to participate in this assessment includes the WebMD privacy statement and the estimated time for completing the assessment. Upon accepting the invitation to participate, a screener “pop-up” box appears. The screener asks the respondent to complete the screener and then instantaneously checks the eligibility criteria. If the respondent meets the criteria for age or living in the U.S., a window with the full KAB assessment will be presented to the respondent.

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. Information gathered will not be used to substantially inform influential policy decisions.

5. The study is not intended to produce results that can be generalized beyond its scope.

Name: ______Jin-Mann S. Lin__________________________________________

To assist review, please answer the following questions:

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

BURDEN HOURS

Category of Respondent	Form Name	No. of Respondents	Participation Time (minutes)	Burden in Hours
General public	Screener	3,800	1	63
General public	KAB survey	3,500	8	467
Totals				530

FEDERAL COST: The estimated annual cost to the Federal government is ____$136,300_______

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 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?

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 all instruments, instructions, and scripts are submitted with the request.

Instructions for completing genIC Request for Approval for

CDC/ATSDR Formative Research and Tool Development

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is requested.

PURPOSE and USE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Briefly describe the targeted group/groups for this collection.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households; (2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected.

Form: Provide the title of the information collection form.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group).

Burden in Minutes: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Estimate the annual cost to the Federal government for this collection.

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

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