genIC Request Form

Attachment D

Request for Approval under Generic ICR

REQUEST FOR APPROVAL UNDER THE GENERIC CLEARANCE FOR ASSESSMENT OF POTENTIAL EXPOSURE FROM PRIVATE WELLS FOR DRINKING WATER

(0920-1173)

Instruction: This form should be completed by the primary contact person from the CDC CIO that will be sponsoring the investigation.

DETERMINE IF YOUR INVESTIGATION IS APPROPRIATE FOR THIS GENERIC CLEARANCE MECHANISM: Instruction: Before completing and submitting this form, determine first if the proposed investigation is appropriate for the Private Well Generic ICR mechanism. Complete the checklist below. If you select “yes” to all criteria, the Private Well Generic IR mechanism can be used.

Criteria

CDC epidemiologic assistance is requested by one or more external partners (e.g., local, state, tribal, other federal agency, or other partner organization).

[ ] Yes [ ] No

The focus of the data collection is to assess potential exposure from private wells for drinking water .

[ ] Yes [ ] No

Results from investigations will be used to improve the requesting agency’s public health activities.

[ ] Yes [ ] No

Investigations will be non-research public health activities designed to prevent or control exposures in the requesting agency’s jurisdiction.

[ ] Yes [ ] No

Did you select “Yes” to all criteria?

If yes, the Private Well Generic ICR may be appropriate for your investigation. → You may proceed with this form.

If no, the Private Well Generic ICR is not appropriate for your investigation. → Stop completing this form now.

TITLE OF INFORMATION COLLECTION: Instruction: Provide the title of the investigation in the following format: [Private well contaminant/issue of interest] for [disease/problem] among [subpopulation] — [State], [Year]

DESCRIPTION OF THIS SPECIFIC COLLECTION

1. Problem to be Investigated: Instruction: Provide a summary of the investigation’s purpose. The summary should include all the information you know at this time about the private well contaminant/issue and why epidemiological assistance was requested. At a minimum, please provide the following information: 1) background necessary to understand the importance of the private well contaminant/issue; 2) justification of the need for an investigation, including a description of any data already available or data gaps that exist; 3) justification as to why this issue requires a response; and 3) an explanation of how the information collected will be used to improve public health activities. Use as much space as necessary (suggested length: 250-500 words).

2. Contaminant of interest: (list all contaminants/issues being investigated)

3. Location of Investigation: Instruction: Indicate location where investigation will occur. If multiple locations, specify each one.

State:

City/County (if applicable):

Region (if applicable):

Territory (if applicable):

4. Agency Requesting Epidemiologic Assistance/Name and Position Title of Requestor

Agency:

Name:

Position Title:

Note: Attach the Letter of Invitation requesting support. The letter should include the following information: 1) background on the contaminant/issue; 2) steps already taken toward prevention and control, if any; 3) request for CDC assistance, including objectives of the investigation; and 4) how data will be used to improve public health activities in the requesting agency’s jurisdiction. Sensitive information in the Letter of Invitation not appropriate for public dissemination should be redacted.

5. Selection of Respondents: Instruction: Provide a brief description of how respondents will be identified and selected. Use as much space as necessary for the description.

6. Data Collection Mode: Instruction: Select all that apply. For each data collection mode planned, provide a brief description. Use as much space as necessary for the description.

[ ] Survey mode (indicate which mode(s) below):

[ ] Face-to-face Interview (describe):

[ ] Telephone Interview (describe):

[ ] Self-administered Paper-and-Pencil Questionnaire (describe):

[ ] Self-administered Internet Questionnaire (describe):

[ ] Other (describe):

[ ] Screening survey mode:

[ ] Face-to-face Interview (describe):

[ ] Telephone Interview (describe):

[ ] Self-administered Paper-and-Pencil Questionnaire (describe):

[ ] Self-administered Internet Questionnaire (describe):

[ ] Other (describe):

7. Type of Information to be Collected: Instruction: Select all that apply. For each type of information to be collected, provide a brief description. Use as much space as necessary for the description.

[ ] General information (describe):

[ ] Socio-demographic information (describe):

[ ] Household water source(s)

[ ] Household water use

[ ] Environmental exposures not related to drinking water from private wells (confounders)

[ ] Perceptions and practices that might affect an individual’s exposure level

[ ] Other (describe):

8. Duration of Data Collection (number of weeks):

INVESTIGATION LEAD: Instruction: Indicate the name, title, and affiliation of the person who will be leading the investigation.

Name:

Title:

Affiliation:

CDC SPONSORING PROGAM AND PRIMARY CONTACT PERSON: Instruction: Indicate the sponsoring CIO/Division/Branch for this investigation. Indicate the name, title, and contact information of the CDC Primary Contact Person for this investigation. Indicate the preferred method of contact during the OMB approval process. Note, contact person or a designee must be available during the OMB approval process in case questions arise.

CIO/Division/Branch:

Name of CDC Sponsoring Program Primary Contact Person:

Title of CDC Sponsoring Program Primary Contact Person:

Contact Information: Provide complete contact information. Check box for preferred method(s) of contact during the OMB approval process.

[ ] Office phone:

[ ] Home phone:

[ ] Cell phone/Blackberry:

[ ] E-mail:

[ ] Other:

CERTIFICATION: Please read the certification carefully. Type your name to validate that you are providing certification. Note: If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved. Certification should be signed by the CDC Primary Contact Person for this Investigation.

I, [INSERT NAME OF CDC SPONSORING PROGRAM CONTACT], certify the following to be true:

1. The collection is voluntary.

2. Respondents will not be personally identified in any published reports of the study.

3. Information gathered will be primarily used to inform effective prevention and control measures.

CDC Sponsoring Program Primary Contact Name:

Date of Certification:

REQUESTED APPROVAL DATE (MM/DD/YYYY): Instruction: Indicate the date by which approval is needed.

DATE SUBMITTED TO INFORMATION COLLECTION REQUEST LIAISON (MM/DD/YYYY): Instruction: Please indicate the date the request is submitted to the ICRL.

E-mail the completed form to the Information Collection Request Liaison (ICRL), Stephanie Davis, at [email protected].

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