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

Forms and Documents

Document Name	Status
Survey to Solicit Feedback on TA on Worker Safety and Health provided as part of COVID response Form	New
Form 0920-0953 Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire Form	New
Form 0920-0953 TWH Webinar Series Form and Instruction	New
Form 0920-20OY Interviews to solicit feedback on COVID-19 Worker Factsheets Form and Instruction	New
Form 0920-0953 NYC Health + Hospitals World Trade Center Environmental Health Center Customer Satisfaction Survey Form	New
Form 0920-0953 Focus Groups-retain Employers Form and Instruction	New
Form 0920-0953 Telehealth Satisfaction at MSSM Form and Instruction	New
Form 0920-0953 NORA CRC Cross-Sector Council Questionnaire Form and Instruction	New
Survey to Solicit Feedback on Expanding Research Partnerships: Federal Govt Form and Instruction	New
Survey to Solicit Feedback on Expanding Research Partnerships: State/Local/Tribal Govt Form and Instruction	New
Survey to Solicit Feedback on Expanding Research Partnerships: Private Sector Form and Instruction	New
Survey to Solicit Feedback on Expanding Research Partnerships: Individuals Form and Instruction	New
2019 NIOSH Centers Grantee Meeting Evaluation Survey Form	New
Form 0920-0953 Mount Sinai World Trade Center Health Program Clinical Center of Excellence Annual Satisfaction Survey Form and Instruction	New
Telehealth Satisfaction at Mt. Sinai School of Medicine (MSSM) Form and Instruction	New
Form 0920-0953 EOHSI/Rutgers Clinical Center of Excellence Annual Monitoring Exam Patient Satisfaction Survey Form and Instruction	New
Customer Survey for the World Trade Center Health Program Nutrition Department (Stony Brook) Form and Instruction	New
Member Satisfaction Survey - Stony Brook Form	New
Form 0920-0953 Telehealth Satisfaction at MSSM Form and Instruction	New
Treatment Satisfaction Survey - NYU Form	New
Form 0920-0953 Winch Entanglement Prevention Technology Interviews Form and Instruction	New
Form 0920-0953 Patient Satisfaction Survey Stony Brook Form	New
Surveillance Systems Feedback Survey Form	New
Three Occupation-specific Units for the Workplace Violence Course: Focus Group Discussions for the Stand-alone Facilities, Home Health/Social Services, and Emergency Responder Units Form and Instruction	New
Form 0920-0953 Patient Satisfaction Survey Stony Brook Form	New
Barriers to Care Assessment for WTC Health Program Care at Mt. Sinai Form and Instruction	New
Form 0920-0953 Worker Notification Feedback Survey Form and Instruction	New
Barriers to Care Assessment for WTC Health Program Care at MSSM Form	New
NIOSH Part SS-A 6.7.18.docx Supporting Statement A	2018-06-21
60-day FRN.pdf Supplementary Document	2018-04-30
Fast_Track_GenIC_RequestTemplate.docx Supplementary Document	2018-02-08
NIOSH Part SS-B 1 29 18.docx Supporting Statement B	2018-02-08

IC Document Collections

IC ID	Document Title	Status
244466	Survey to Solicit Feedback on TA on Worker Safety and Health provided as part of COVID response Form	New
243427	Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire Form	New
242833	TWH Webinar Series Form and Instruction	New
242116	Interviews to solicit feedback on COVID-19 Worker Factsheets Form and Instruction	New
241811	Occupational Exposure Banding Survey Other-WORD	New
240895	NYC Health + Hospitals World Trade Center Environmental Health Center Customer Satisfaction Survey Form	New
240720	Focus Groups-retain Employers Form and Instruction	New
239432	Telehealth Satisfaction at MSSM Form and Instruction	New
238921	Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire Other-WORD.doc	New
238377	NORA CRC Cross-Sector Council Questionnaire Form and Instruction	New
237984	Survey to Solicit Feedback on Expanding Research Partnerships: Federal Govt Form and Instruction	New
237983	Survey to Solicit Feedback on Expanding Research Partnerships: State/Local/Tribal Govt Form and Instruction	New
237982	Survey to Solicit Feedback on Expanding Research Partnerships: Private Sector Form and Instruction	New
237926	Occupational Data for Health (ODH) Prototype usability testing Other-header	New
237902	Survey to Solicit Feedback on Expanding Research Partnerships: Individuals Form and Instruction	New
237772	2019 NIOSH Centers Grantee Meeting Evaluation Survey Form	New
237578	Mount Sinai World Trade Center Health Program Clinical Center of Excellence Annual Satisfaction Survey Form and Instruction	New
236605	Telehealth Satisfaction at Mt. Sinai School of Medicine (MSSM) Form and Instruction	New
236603	EOHSI/Rutgers Clinical Center of Excellence Annual Monitoring Exam Patient Satisfaction Survey Form and Instruction	New
236078	Customer Survey for the World Trade Center Health Program Nutrition Department (Stony Brook) Form and Instruction	New
235814	Course Evaluation for Continuing Education Webinars-WTCHP Other-WORD	New
235413	Member Satisfaction Survey - Stony Brook Form	New
235412	Telehealth Satisfaction at MSSM Form and Instruction	New
235409	Treatment Satisfaction Survey - NYU Form	New
235160	Winch Entanglement Prevention Technology Interviews Form and Instruction	New
234904	Patient Satisfaction Survey Stony Brook Form	New
233405	Surveillance Systems Feedback Survey Form	New
233232	Three Occupation-specific Units for the Workplace Violence Course: Focus Group Discussions for the Stand-alone Facilities, Home Health/Social Services, and Emergency Responder Units Form and Instruction	New
233061	Patient Satisfaction Survey Stony Brook Form	New
232998	Barriers to Care Assessment for WTC Health Program Care at Mt. Sinai Form and Instruction	New
232892	Worker Notification Feedback Survey Form and Instruction	New
232864	Barriers to Care Assessment for WTC Health Program Care at MSSM Form	New

ICR Details

OMB Control No: 0920-0953	ICR Reference No: 201802-0920-007
Status: Active	Previous ICR Reference No: 201505-0920-003
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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/27/2018
	Date Received in OIRA: 06/27/2018
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.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2021	36 Months From Approved	08/31/2018
Responses	154,800	0	229,800
Time Burden (Hours)	39,225	0	57,975
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:
	83 FR 12766	03/23/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 29558	06/25/2018
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 32

IC Title	Form No.	Form Name
Three Occupation-specific Units for the Workplace Violence Course: Focus Group Discussions for the Stand-alone Facilities, Home Health/Social Services, and Emergency Responder Units	n/a	Focus Group Discussion Guide for Online Workplace Violence Prevention Best Practices Courses
Telehealth Satisfaction at MSSM	0920-0953	Telehealth Satisfaction Survey
Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire
Winch Entanglement Prevention Technology Interviews	0920-0953, 0920-0953	Opening Script and Eligibility Screening Form ,   Representative Question Stems for Interviews
Patient Satisfaction Survey Stony Brook	0920-0953	Patient Satisfaction Survey
Barriers to Care Assessment for WTC Health Program Care at Mt. Sinai	none, none, none	Member Questionnaire - English ,   Member Questionnaire - Polish ,   Member Questionnaire - Spanish
Treatment Satisfaction Survey - NYU	none, none	Treatment Satisfaction Survey - English ,   Treament Satisfaction Survey - Spanish
Mount Sinai WTC Health Program Clinical Center of Excellence After Visit Questionnaire	0920-0953	Telehealth Services Satisfaction Questionnaire
Barriers to Care Assessment for WTC Health Program Care at MSSM	none	Barriers to Care Assessment
Occupational Data for Health (ODH) Prototype usability testing	0920-0953, 0920-0953, 0920-0953, 0920-0953, 0920-0953, 0920-0953	Occupational Data for Health (OHD) Phototype Version 3 ,   Employment Status & Retirement dates ,   Longest Held Occupation ,   Work History ,   PRE-TEST DEMOGRAPHIC DATA SURVEY FOR OCCUPATIONAL DATA FOR HEALTH (ODH) PROTOTYPE USABILITY TESTING ,   POST-TEST SURVEY FOR OCCUPATIONAL DATA FOR HEALTH (ODH)
Interviews to solicit feedback on COVID-19 Worker Factsheets	0920-20OY	Fact sheet testing interview instrument
Worker Notification Feedback Survey	0920-0953	Worker Notification Feedback Survey
Patient Satisfaction Survey Stony Brook	0920-0953, 0920-0953	Participation in WTC Health Program at NYUSOM Clinical Center of Excellence ,   Participation in WTC Health Program at NYUSOM Clinical Center of Excellence (Spanish Version)
EOHSI/Rutgers Clinical Center of Excellence Annual Monitoring Exam Patient Satisfaction Survey	0920-0953	Rutgers Patient Satisfaction Survey 2019
Mount Sinai World Trade Center Health Program Clinical Center of Excellence Annual Satisfaction Survey	0920-0953	WTC Mt. Sinai Medical Center Annual Survey
2019 NIOSH Centers Grantee Meeting Evaluation Survey	none	Grantee Meeting Evaluation
Customer Survey for the World Trade Center Health Program Nutrition Department (Stony Brook)	n/a	World Trade Center Health Program Nutrition Survey
Occupational Exposure Banding Survey
Focus Groups-retain Employers	0920-0953, 0920-0953	Focus Group Discussion Guide For Employers ,   Focus Group Discussion Guide For Employees
TWH Webinar Series	0920-0953	Webinar Questions
Surveillance Systems Feedback Survey	none	Systems Application Feedback
Course Evaluation for Continuing Education Webinars-WTCHP
NORA CRC Cross-Sector Council Questionnaire	0920-0953	Cross-Sector Survey
Survey to Solicit Feedback on Expanding Research Partnerships: State/Local/Tribal Govt	n/a	Feedback Survey on the "Expanding Research Partnerships" webinar series
Survey to Solicit Feedback on Expanding Research Partnerships: Individuals	n/a	Feedback Survey on the "Expanding Research Partnerships" webinar series
NYC Health + Hospitals World Trade Center Environmental Health Center Customer Satisfaction Survey	0920-0953	WTC Environmental Health Center Customer Satisfaction Survey
Survey to Solicit Feedback on TA on Worker Safety and Health provided as part of COVID response	none, none	Field TA Survey ,   Virtual TA Survey
Member Satisfaction Survey - Stony Brook	none	Member Satisfaction Survey
Survey to Solicit Feedback on Expanding Research Partnerships: Federal Govt	n/a	Feedback Survey on the "Expanding Research Partnerships" webinar series
Survey to Solicit Feedback on Expanding Research Partnerships: Private Sector	n/a	Feedback Survey on the "Expanding Research Partnerships" webinar series
Telehealth Satisfaction at Mt. Sinai School of Medicine (MSSM)	n/a	Telehealth Services Patient Satisfaction Questionnaire
Telehealth Satisfaction at MSSM	0920-0953	TMH QA Questionnaire

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ICR Summary 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	229,800	0	-75,000	0	0
Annual Time Burden (Hours)	39,225	57,975	0	-18,750	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Burden reduction due to adjusting for unused hours and planned efforts within NIOSH for next three years.

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Annual Cost to Federal Government: $112,000

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? Uncollected

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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: 06/27/2018

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