GenIC Request Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-1050)

Instruction: This form should be completed by the primary contact person from the Program sponsoring the collection.

DETERMINE IF YOUR COLLECTION IS APPROPRIATE FOR THIS GENERIC CLEARANCE MECHANISM:

Instruction: Before completing and submitting this form, determine first if the proposed collection is consistent with the scope of the Collection of Routine Customer Feedback generic clearance mechanism. To determine the appropriateness of using the Collection of Routine Customer Feedback generic clearance mechanism, complete the checklist below.

If you select “yes” to all criteria in Column A, the Collection of Routine Customer Feedback generic clearance mechanism can be used. If you select “yes” to any criterion in Column B, the Collection of Routine Customer Feedback generic clearance mechanism cannot be used.

Column A	Column B
The information gathered will only be used internally to CDC. [X ] Yes [ ] No	Information gathered will be publicly released or published. [ ] Yes [X] No
Data is qualitative in nature and not generalizable to people from whom data was not collected. [X ] Yes [ ] No	Employs quantitative study design (e.g. those that rely on probability design or experimental methods) [ ] Yes [X] No
There are no sensitive questions within this collection (e.g. sexual orientation, gender identity). [X] Yes [ ] No	Sensitive questions will be asked (e.g. sexual orientation, gender identity). [ ] Yes [X] No
Collection does not raise issues of concern to any other Federal agencies. [X] Yes [ ] No	Other Federal agencies may have equities or concerns regarding this collection. [ ] Yes [X] No
Data collection is focused on determining ways to improve delivery of services to customers of a current CDC program. [X] Yes [ ] No	Data will be used to inform programmatic or budgetary decisions, for the purpose of program evaluation, for surveillance, for program needs assessment, or for research. [ ] Yes [X] No
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. [X] Yes [ ] No

Did you select “Yes” to all criteria in Column A?

If yes, the Collection of Routine Customer Feedback generic clearance mechanism may be appropriate for your investigation. You may proceed with this form.

Did you select “Yes” to any criterion in Column B?

If yes, the Collection of Routine Customer Feedback generic clearance mechanism is NOT appropriate for your investigation. Stop completing this form now.

TITLE OF INFORMATION COLLECTION: Interviews to identify customers’ pain points and opportunities in collecting, managing, and using data to inform the design of shared services between the CDC and state, territorial, and local public health authorities.

PURPOSE:

This effort is part of a cooperative agreement between the CDC and the CDC Foundation to understand the best potential design and implementation for shared services between the CDC and state, territorial, and local public health authorities.

The purpose of these interviews is to inform how the CDC prioritizes and designs shared services: interoperable services or tools that can be shared across organizations, diseases, and data sources (e.g., case reports, lab results), in order to allow organizations to look to others prior to purchasing technology or upgrading systems. Specifically, we want to identify state, local and territorial health authorities’ staff’s frustrations, needs, and desired outcomes along workflows of data ecosystem that could best inform priorities and decision-making for how, and if, shared services could be leveraged to support the public health ecosystem in surveillance, response, and assessment.

DESCRIPTION OF RESPONDENTS:

Respondents are state, local, and territorial public health agency staff who interact with data at any point along the data ecosystem. This can include IT staff, informatics staff, epidemiologists, administrators, nurses, among other types of staff.

TYPE OF COLLECTION: (Check one)

Instruction: Please sparingly use the Other category

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

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

[ ] Focus Group [X ] Other: Interviews

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.

Name:_Celeste Espinoza

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

Personally Identifiable Information:

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

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [X] No

If Yes: Please describe the incentive. If amounts are outside of customary incentives, please also provide a justification

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
State, territorial, or local, public health authorities	300	1 hour	300 hours
Totals	300	1 hour	300 hours

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 Yes: Please provide a description of both below (or attach the sampling plan)

1. Customer list that defines the universe of potential respondents: As part of the CDC Data Modernization Initiative (DMI), we asked State, Territory, Local, Tribal (STLT) health department staff who touch data at any point along the data ecosystem (e.g., collection to reporting) to sign up to participate in future research and pilot partner activities. In this sign-up sheet, they listed their health department, type of health department (e.g., local, state, territory), and areas of expertise.

2. Sampling plan: We plan to extend invitations to invite all those on the list (above) who meet our inclusion criteria for the interviews. The interviews will be segmented by topic, and type of health department (local health departments, state/territory/big city health departments) and job role.

If No: Please provide a description of how you plan to identify your potential group of respondents and how you will select them or ask them to self-select/volunteer

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ X ] Other, Explain Word or Excel documents will capture raw notes for further analysis, Mural board templates

2. Will interviewers or facilitators be used? [X] Yes [ ] No

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

Provided in Attachment A and B.

5