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
Form 0923-0047 Facilitated Community Health Center (CHC) Feedback Session with CHC NON-USER Non-Physician Clinic Staff	Form and Instruction	New	Repair queued
Form 0923-0047 Facilitated Community Health Center (CHC) Feedback Session with CHC USER Non-Physician Clinic Staff	Form and Instruction	New	Repair queued
Form 0923-0047 Facilitated Community Health Center (CHC) Feedback Session with CHC NON-USER Physicians	Form and Instruction	New	Repair queued
Form 0923-0047 Facilitated Community Health Center (CHC) Feedback Session with CHC USER Physicians	Form and Instruction	New	Repair queued
Form 0923-0047-24FL Laboratorian who submits PT results to NSMBB	Form	New	Repair queued
Meeting Presenters Evaluation Form	Form and Instruction	New	Repair queued
Meeting Attendees Evaluation Form	Form and Instruction	New	Repair queued
Form 0920 Page 1 Heat and Health Tracker Evaluation Survey	Form and Instruction	New	Available
Form 0923-0047 AttD EJI Explorer Demo Session Survey (Word)	Form and Instruction	New	Available
Form 0923-0047 AttC EJI Use Case Breakout Session Survey (Word)	Form and Instruction	New	Repair queued
Form 0923-0047 AttB EJI Breakout Session Survey (online)	Form and Instruction	New	Available
EHLR Immersion Pilot Training Feedback Form	Form and Instruction	New	Available
EHLR Immersion Community Engagement Knowledge Assessment	Form and Instruction	New	Available
EHLR Training Registration-Pilots	Form and Instruction	New	Available
Att 4 ATSDR 0923-0047 GnrcClrncQualFdbkTmpltapprvlFrm.docx	Supplementary Document	Uploaded 2021-10-29	Repair queued
Att 3- Srvc Dlvry HS Determination.pdf	Supplementary Document	Uploaded 2021-10-29	Available
Att 2 60D FRN 0923-0047 2021.pdf	Supplementary Document	Uploaded 2021-10-29	Repair queued
1 - ATSDR 0923-0047 Extnsn 2021 SSB.docx	Supporting Statement B	Uploaded 2021-10-29	Repair queued
Att 1 EO12862 - Authority.pdf	Supplementary Document	Uploaded 2021-10-29	Repair queued
1 - ATSDR 0923-0047 Extnsn 2021 SSAv2.docx	Supporting Statement A	Uploaded 2021-10-29	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
270947	[ATSDR] Community Health Center Physician and Non-Physician Discussions on CDC's new Heat Clinical Guidance	Form and Instruction	New	Facilitated Community Health Center (CHC) Feedback Session with CHC NON-USER Non-Physician Clinic Staff
270947	[ATSDR] Community Health Center Physician and Non-Physician Discussions on CDC's new Heat Clinical Guidance	Form and Instruction	New	Facilitated Community Health Center (CHC) Feedback Session with CHC USER Non-Physician Clinic Staff
270947	[ATSDR] Community Health Center Physician and Non-Physician Discussions on CDC's new Heat Clinical Guidance	Form and Instruction	New	Facilitated Community Health Center (CHC) Feedback Session with CHC NON-USER Physicians
270947	[ATSDR] Community Health Center Physician and Non-Physician Discussions on CDC's new Heat Clinical Guidance	Form and Instruction	New	Facilitated Community Health Center (CHC) Feedback Session with CHC USER Physicians
267618	[ATSDR] Quality Improvements to NSMBB's quality assurance systems, processes, infrastructure, and workflow to create efficiencies and enhance service delivery	Form	New	Laboratorian who submits PT results to NSMBB
260213	[ATSDR] Evaluation of CDC Childhood Lead Poisoning Prevention Program (CLPPP) Annual Recipients Meeting	Form and Instruction	New	Meeting Presenters Evaluation Form
260213	[ATSDR] Evaluation of CDC Childhood Lead Poisoning Prevention Program (CLPPP) Annual Recipients Meeting	Form and Instruction	New	Meeting Attendees Evaluation Form
259233	[ASTDR] Training for Home Visitors Assessing Asthma Triggers	Other-WORD	New
259022	[ATSDR] Heat and Health Tracker Evaluation Survey	Form and Instruction	New	Page 1 Heat and Health Tracker Evaluation Survey
259022	[ATSDR] Heat and Health Tracker Evaluation Survey	Other-WORD	New
258785	[ATSDR] Environmental Justice Index Workshop Feedback Surveys	Form and Instruction	New	AttD EJI Explorer Demo Session Survey (Word)
258785	[ATSDR] Environmental Justice Index Workshop Feedback Surveys	Form and Instruction	New	AttC EJI Use Case Breakout Session Survey (Word)
258785	[ATSDR] Environmental Justice Index Workshop Feedback Surveys	Form and Instruction	New	AttB EJI Breakout Session Survey (online)
258593	[ATSDR] Environmental Health and Land Reuse (EHLR) Immersion Training Pilots	Form and Instruction	New	EHLR Immersion Pilot Training Feedback Form
258593	[ATSDR] Environmental Health and Land Reuse (EHLR) Immersion Training Pilots	Form and Instruction	New	EHLR Immersion Community Engagement Knowledge Assessment
258593	[ATSDR] Environmental Health and Land Reuse (EHLR) Immersion Training Pilots	Form and Instruction	New	EHLR Training Registration-Pilots
258593	[ATSDR] Environmental Health and Land Reuse (EHLR) Immersion Training Pilots	Other-WORD	New

ICR Details

OMB Control No: 0923-0047	ICR Reference No: 202110-0923-002
Status: Historical Active	Previous ICR Reference No: 201810-0923-002
Agency/Subagency: HHS/TSDR	Agency Tracking No: Docket ATSDR-2021-0003
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/17/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/16/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2025	36 Months From Approved	02/28/2022
Responses	24,900	0	24,900
Time Burden (Hours)	21,225	0	21,225
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information is necessary to enable the Agency to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the Agency's programs. Each project-specific information collection (GENIC) will be submitted to OMB for approval.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

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 16212	03/26/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 63392	11/16/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
[ASTDR] Training for Home Visitors Assessing Asthma Triggers
[ATSDR] Community Health Center Physician and Non-Physician Discussions on CDC's new Heat Clinical Guidance	0923-0047, 0923-0047, 0923-0047, 0923-0047	Facilitated Community Health Center (CHC) Feedback Session with CHC USER Physicians ,   Facilitated Community Health Center (CHC) Feedback Session with CHC NON-USER Physicians ,   Facilitated Community Health Center (CHC) Feedback Session with CHC USER Non-Physician Clinic Staff ,   Facilitated Community Health Center (CHC) Feedback Session with CHC NON-USER Non-Physician Clinic Staff
[ATSDR] Environmental Health and Land Reuse (EHLR) Immersion Training Pilots	None, None, None	EHLR Training Registration-Pilots ,   EHLR Immersion Community Engagement Knowledge Assessment ,   EHLR Immersion Pilot Training Feedback Form
[ATSDR] Environmental Justice Index Workshop Feedback Surveys	0923-0047, 0923-0047, 0923-0047	AttB EJI Breakout Session Survey (online) ,   AttC EJI Use Case Breakout Session Survey (Word) ,   AttD EJI Explorer Demo Session Survey (Word)
[ATSDR] Evaluation of CDC Childhood Lead Poisoning Prevention Program (CLPPP) Annual Recipients Meeting	n/a, n/a	Meeting Attendees Evaluation Form ,   Meeting Presenters Evaluation Form
[ATSDR] Heat and Health Tracker Evaluation Survey	0920	Page 1 Heat and Health Tracker Evaluation Survey
[ATSDR] Quality Improvements to NSMBB's quality assurance systems, processes, infrastructure, and workflow to create efficiencies and enhance service delivery	0923-0047-24FL	Laboratorian who submits PT results to NSMBB

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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	24,900	24,900	0	0	0	0
Annual Time Burden (Hours)	21,225	21,225	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: $500,000

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: 11/16/2021

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