Request for Approval under the “Generic Clearance

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-1071)

TITLE OF INFORMATION COLLECTION: HAI/AR Program Multi-Drug Resistant Organism (MDRO) Prevention and Response Needs Assessment Survey

PURPOSE:

This survey is a standardized needs assessment tool to identify, among Hospital-associated Infections and Antimicrobial Resistance (HAI/AR) programs (located at state and local health departments) that received supplemental American Rescue Plan funding for Strengthening Healthcare and Antimicrobial Resistance Programs (SHARP), the areas of greatest need for effective implementation of MDRO prevention and response strategies. Based on reported needs, CDC will develop solutions for providing technical assistance and strengthening jurisdictional capacity for preventing transmission of targeted and novel MDROs. Reviewing and assessing these needs is critical to providing appropriate support and educational resources, due to substantial changes in MDRO prevalence, HAI/AR program staffing, and healthcare facility staffing and practices resulting from the COVID-19 pandemic.

DESCRIPTION OF RESPONDENTS:

Respondents are state and local government HAI/AR programs. HAI/AR programs are in public health departments that received funding under the Epidemiology and Laboratory Capacity (ELC) Cooperative Agreement. The survey will be completed by 2-3 senior or mid-level staff from each ELC-funded public health jurisdictional HAI/AR program (64 maximum participating jurisdictions).

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [X] Other: Program Capacity Assessment Survey

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. The results are not intended to be disseminated to the public.

5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

Name:_____Maroya Walters___________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [X] Yes [ ] No

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [ X] 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	No. of Respondents	Participation Time	Burden
State, local, or tribal governments (HAI/AR program within ELC-funded jurisdiction)	64 programs (1-3 staff within each program would contribute to program survey)	1.5 hours	96 hours
Totals	64 programs	1.5 hours	96 hours total

FEDERAL COST: The estimated annual cost to the Federal government is ______$0______

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? [X] Yes [ ] 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?

Respondents completing the tool are HAI/AR programs, the individuals competing the tool on behalf of their programs are senior and mid-level staff (e.g. HAI/AR Team Lead, Lead Infectious Disease Epidemiologist, etc.) that work within the HAI/AR program of each public health jurisdiction that received ELC funding. Up to 64 ELC-funded jurisdictions are anticipated to participate.

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

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g., Comment card for soliciting feedback on xxxx)

PURPOSE: 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: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

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.

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: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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