Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Survey Questions	Form	New	Repair queued
Form 0920-0953 Building a System Where Healthcare Workers Thrive Virtual Workshop Feedback Form	Form and Instruction	New	Repair queued
Form 0920-0953 Fostering a Safe, Supportive Work Environment Virtual Workshop Feedback Form - Survey 2	Form and Instruction	New	Repair queued
Form 0920-0953 Getting Started to Impact Wellbeing Virtual Workshop Feedback Form - Survey 1	Form and Instruction	New	Repair queued
Survey	Form and Instruction	New	Repair queued
Check-in Session Discussion Guide	Form and Instruction	New	Repair queued
NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #6	Form and Instruction	New	Repair queued
NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #5	Form and Instruction	New	Repair queued
NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #4	Form and Instruction	New	Repair queued
NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #3	Form and Instruction	New	Repair queued
NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #2	Form and Instruction	New	Repair queued
NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #1	Form and Instruction	New	Repair queued
Form 0920-23ET CDC Focus Group Discussion Guide_Attachment 3_employers_supervisors	Form and Instruction	New	Repair queued
Form 0920-23ET CDC Focus Group Discussion Guide - Attachment 2_SPANISH	Form and Instruction	New	Repair queued
Form 0920-23ET CDC Focus Group Discussion Guide_Attachment 1	Form and Instruction	New	Repair queued
Form 0920-0953 Evaluation of the NIOSH Healthcare Worker Mental Health Campaign	Form	New	Repair queued
Form 0920-0953 NORA Services Sector Council Member Questionnaire	Form	New	Repair queued
Informed Consent (Spanish)	Form and Instruction	New	Repair queued
Usability Testing Guide (Spanish)	Form and Instruction	New	Repair queued
Informed Consent	Form and Instruction	New	Repair queued
Usability Testing Guide	Form and Instruction	New	Repair queued
Employers Focus Group	Form and Instruction	New	Repair queued
Employee Focus Groups Younger Workers	Form and Instruction	New	Repair queued
Employee Focus Groups Older Workers	Form and Instruction	New	Repair queued
Screener and Demographic Questionnaire: Workers	Form and Instruction	New	Repair queued
Screening Tool for Recruitment: Employers	Form and Instruction	New	Repair queued
Questionnaire	Form and Instruction	New	Repair queued
Clinical Laboratory Partners Forum meeting evaluation survey	Form and Instruction	New	Repair queued
Form 0920-0953 Survey Questionnaire	Form and Instruction	New	Available
NIOSH Occupational Exposure Banding Survey (PDF of Survey Monkey)	Form and Instruction	New	Available
NIOSH Occupational Exposure Banding Survey	Form and Instruction	New	Available
NIOSH Part SS-A 7.7.21_final.docx	Supporting Statement A	Uploaded 2021-08-05	Repair queued
0920-0953 60day FRN.pdf	Supplementary Document	Uploaded 2021-07-15	Repair queued
Fast_Track_GenIC_RequestTemplate.docx	Supplementary Document	Uploaded 2021-07-15	Repair queued
NIOSH Part SS-B 7.7.21.docx	Supporting Statement B	Uploaded 2021-07-15	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
267467	[NIOSH] NIOSH Approved Radiograph Facility Quality Assurance Program Customer Satisfaction Survey	Form	New	Survey Questions
266320	[NIOSH] : Satisfaction Survey for three-part virtual workshop series on Impact Wellbeing™ Guide	Form and Instruction	New	Building a System Where Healthcare Workers Thrive Virtual Workshop Feedback Form
266320	[NIOSH] : Satisfaction Survey for three-part virtual workshop series on Impact Wellbeing™ Guide	Form and Instruction	New	Fostering a Safe, Supportive Work Environment Virtual Workshop Feedback Form - Survey 2
266320	[NIOSH] : Satisfaction Survey for three-part virtual workshop series on Impact Wellbeing™ Guide	Form and Instruction	New	Getting Started to Impact Wellbeing Virtual Workshop Feedback Form - Survey 1
263104	[NIOSH] Data collection for evidence-based revisions to the Fire Fighter Fatality Investigation and Prevention Program's Medical Line of Duty Death reports	Other-WORD	New
260988	[NIOSH] Worker Notification User Feedback Survey (Comment Card)	Form and Instruction	New	Survey
260133	[NIOSH] NIOSH Health Worker Mental Health Campaign: Implementation Guide Usability Testing	Form and Instruction	New	Check-in Session Discussion Guide
260133	[NIOSH] NIOSH Health Worker Mental Health Campaign: Implementation Guide Usability Testing	Form and Instruction	New	NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #6
260133	[NIOSH] NIOSH Health Worker Mental Health Campaign: Implementation Guide Usability Testing	Form and Instruction	New	NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #5
260133	[NIOSH] NIOSH Health Worker Mental Health Campaign: Implementation Guide Usability Testing	Form and Instruction	New	NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #4
260133	[NIOSH] NIOSH Health Worker Mental Health Campaign: Implementation Guide Usability Testing	Form and Instruction	New	NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #3
260133	[NIOSH] NIOSH Health Worker Mental Health Campaign: Implementation Guide Usability Testing	Form and Instruction	New	NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #2
260133	[NIOSH] NIOSH Health Worker Mental Health Campaign: Implementation Guide Usability Testing	Form and Instruction	New	NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #1
260092	[NIOSH] Focus groups to obtain input from construction workers and employers	Form and Instruction	New	CDC Focus Group Discussion Guide_Attachment 3_employers_supervisors
260092	[NIOSH] Focus groups to obtain input from construction workers and employers	Form and Instruction	New	CDC Focus Group Discussion Guide - Attachment 2_SPANISH
260092	[NIOSH] Focus groups to obtain input from construction workers and employers	Form and Instruction	New	CDC Focus Group Discussion Guide_Attachment 1
258002	[NOISH] Mental Health Campaign Website Feedback Survey	Form	New	Evaluation of the NIOSH Healthcare Worker Mental Health Campaign
257886	[NOISH] NORA Services Sector Council Member Questionnaire	Form	New	NORA Services Sector Council Member Questionnaire
257752	[NIOSH] Usability Testing of Toolbox Talks for Landscaping and Tree Care Workers	Form and Instruction	New	Informed Consent (Spanish)
257752	[NIOSH] Usability Testing of Toolbox Talks for Landscaping and Tree Care Workers	Form and Instruction	New	Usability Testing Guide (Spanish)
257752	[NIOSH] Usability Testing of Toolbox Talks for Landscaping and Tree Care Workers	Form and Instruction	New	Informed Consent
257752	[NIOSH] Usability Testing of Toolbox Talks for Landscaping and Tree Care Workers	Form and Instruction	New	Usability Testing Guide
257214	[NIOSH] Virtual Focus Groups to Obtain Feedback from Retail Employers and Employees on WMSDs and STFs	Form and Instruction	New	Employers Focus Group
257214	[NIOSH] Virtual Focus Groups to Obtain Feedback from Retail Employers and Employees on WMSDs and STFs	Form and Instruction	New	Employee Focus Groups Younger Workers
257214	[NIOSH] Virtual Focus Groups to Obtain Feedback from Retail Employers and Employees on WMSDs and STFs	Form and Instruction	New	Employee Focus Groups Older Workers
257214	[NIOSH] Virtual Focus Groups to Obtain Feedback from Retail Employers and Employees on WMSDs and STFs	Form and Instruction	New	Screener and Demographic Questionnaire: Workers
257214	[NIOSH] Virtual Focus Groups to Obtain Feedback from Retail Employers and Employees on WMSDs and STFs	Form and Instruction	New	Screening Tool for Recruitment: Employers
257213	Customer Survey to Solicit Feedback on NIOSH Workplace Guidance Documents	Form and Instruction	New	Questionnaire
254299	Data collection for evidence-based revisions to the Fire Fighter Fatality Investigation and Prevention Program Line of Duty Death reports	Other-Screening questions	New
253951	[CSELS] DLS CLPF Meeting Evaluation Survey 2022	Form and Instruction	New	Clinical Laboratory Partners Forum meeting evaluation survey
251396	Communication Community of Practice Meetings	Form and Instruction	New	Survey Questionnaire
250342	[2022] Occupational Exposure Banding (OEB) Evaluation Survey	Form and Instruction	New	NIOSH Occupational Exposure Banding Survey (PDF of Survey Monkey)
250342	[2022] Occupational Exposure Banding (OEB) Evaluation Survey	Form and Instruction	New	NIOSH Occupational Exposure Banding Survey

ICR Details

OMB Control No: 0920-0953	ICR Reference No: 202107-0920-007
Status: Historical Active	Previous ICR Reference No: 201802-0920-007
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0953
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
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: 10/27/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/11/2021
Terms of Clearance: OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2024	36 Months From Approved	10/31/2021
Responses	154,800	0	154,800
Time Burden (Hours)	39,225	0	39,225
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information is necessary to enable the CDC/NIOSH to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The types of collections that this generic clearance covers include, but are not limited to: Customer comment cards/complaint forms, Small discussion groups, Focus Groups of customers, potential customers, delivery partners, or other stakeholders, Cognitive laboratory studies, such as those used to refine questions or assess usability of a website, Qualitative customer satisfaction surveys (e.g., post-transaction surveys; opt-out web surveys) and In-person observation testing (e.g., website or software usability tests).

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
   PL: Pub.L. 91 - 596 20 Name of Law: Occupational Safety and Health Act of 1970
  

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:
	86 FR 24621	05/07/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 43253	08/06/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Communication Community of Practice Meetings	0920-0953	Survey Questionnaire
Customer Survey to Solicit Feedback on NIOSH Workplace Guidance Documents	n/a	Questionnaire
Data collection for evidence-based revisions to the Fire Fighter Fatality Investigation and Prevention Program Line of Duty Death reports
[2022] Occupational Exposure Banding (OEB) Evaluation Survey	n/a, n/a	NIOSH Occupational Exposure Banding Survey ,   NIOSH Occupational Exposure Banding Survey (PDF of Survey Monkey)
[CSELS] DLS CLPF Meeting Evaluation Survey 2022	None	Clinical Laboratory Partners Forum meeting evaluation survey
[NIOSH] : Satisfaction Survey for three-part virtual workshop series on Impact Wellbeing™ Guide	0920-0953, 0920-0953, 0920-0953	Getting Started to Impact Wellbeing Virtual Workshop Feedback Form - Survey 1 ,   Fostering a Safe, Supportive Work Environment Virtual Workshop Feedback Form - Survey 2 ,   Building a System Where Healthcare Workers Thrive Virtual Workshop Feedback Form
[NIOSH] Data collection for evidence-based revisions to the Fire Fighter Fatality Investigation and Prevention Program's Medical Line of Duty Death reports
[NIOSH] Focus groups to obtain input from construction workers and employers	0920-23ET, 0920-23ET, 0920-23ET	CDC Focus Group Discussion Guide_Attachment 1 ,   CDC Focus Group Discussion Guide - Attachment 2_SPANISH ,   CDC Focus Group Discussion Guide_Attachment 3_employers_supervisors
[NIOSH] NIOSH Approved Radiograph Facility Quality Assurance Program Customer Satisfaction Survey	n/a	Survey Questions
[NIOSH] NIOSH Health Worker Mental Health Campaign: Implementation Guide Usability Testing	None, None, None, None, None, None, None	NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #1 ,   NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #2 ,   NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #3 ,   NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #4 ,   NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #5 ,   NIOSH Health Worker Mental Health Campaign Implementation Guide Feedback Survey #6 ,   Check-in Session Discussion Guide
[NIOSH] Usability Testing of Toolbox Talks for Landscaping and Tree Care Workers	n/a, n/a, n/a, n/a	Usability Testing Guide ,   Informed Consent ,   Usability Testing Guide (Spanish) ,   Informed Consent (Spanish)
[NIOSH] Virtual Focus Groups to Obtain Feedback from Retail Employers and Employees on WMSDs and STFs	None, None, None, None, None	Screening Tool for Recruitment: Employers ,   Screener and Demographic Questionnaire: Workers ,   Employee Focus Groups Older Workers ,   Employee Focus Groups Younger Workers ,   Employers Focus Group
[NIOSH] Worker Notification User Feedback Survey (Comment Card)	n/a	Survey
[NOISH] Mental Health Campaign Website Feedback Survey	0920-0953	Evaluation of the NIOSH Healthcare Worker Mental Health Campaign
[NOISH] NORA Services Sector Council Member Questionnaire	0920-0953	NORA Services Sector Council Member Questionnaire

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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	154,800	154,800	0	0	0	0
Annual Time Burden (Hours)	39,225	39,225	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $97,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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? No

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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: 08/11/2021

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