0920-1050 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? Yes

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? No

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:

HMIS and IIS Integration Survey to Improve Vaccination Rate Tracking among People Experiencing Homelessness (PEH)

PURPOSE:

CDC is partnering with IIS and HMIS users (at state and local jurisdictions) and vendors of Immunization information systems (IIS) and Homeless Management Information Systems (HMIS) to improve service. CDC provides funding for IIS services and systems and develops the standards that IIS systems are required to follow. CDC also provides public heath surveillance, public health emergency response services, and immunization reporting services that impact the population of people experiencing homelessness. The goal of this project is to improve CDC public health services focused on people experiencing homelessness through collecting information to enable integration of IIS and HMIS. Information gathered will be internal to CDC as the first step in a project to work toward future system integration to improve services.

DESCRIPTION OF RESPONDENTS:

Potential respondents will include users of Homeless Management Information Systems (HMIS) and Immunization information systems (IIS), vendors or implementers of HMIS and IIS systems. HMIS/IIS users include staff users at state and local jurisdictions as well as staff working for Continuums of Care, which are the selected community partners of Housing and Urban Development (HUD) homelessness/housing programs in a given area.

TYPE OF COLLECTION: (Check one)

Instruction: Please sparingly use the Other category

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

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

[ ] Focus Group [ ] Other: _

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:__Kristie E. N. Clarke, MD MSCR________________________________________

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [] Yes [X] 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

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 (In hours)
Users of HMIS, including jurisdictional staff and staff of HUD Continuums of Care	400	10 min	67
Vendors of HMIS systems	23	10 min	4
Vendors / implementers of IIS systems	12	10 min	2
IIS Users, including jurisdictional immunization programs	115	10 min	19
Totals	550	10 min each	92

FEDERAL COST:  The estimated annual cost to the Federal government is $6,145. This is based on pay for three positions. The first position estimate is based on the time required for one contractor to design survey and reach out to potential respondents through partner organizations. The second position is for a contractor to coordinate receipt of survey data. The third position is a contractor to conduct a descriptive analysis of results.

Estimated Annualized Cost to the Federal Government

Staff (FTE)	Estimated Hours	Hourly Rate	Total Cost
Contractor- Project Lead: Design of survey interview guide; outreach to IIS and HMIS programs and vendors to distribute surveys	25 (0.01 Contractor)	$100/hour	$2500
Contractor- Technical Consultant: Coordination of receipt of survey data	10 (0.01 Contractor)	$195/hour	$195
Contractor- Subject Matter Consultant: Descriptive analysis of data	30 (0.01 Contractor)	$115/hour	$3,450
Survey software- no cost will use existing account of contracted partner (AIRA) with Survey Monkey	N/A	$0	$0
Total			$6,145

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)

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

The contracted organization (American Immunization Registry Association, hereafter AIRA) has ongoing relationships with IIS staff in all jurisdictions. AIRA also has a list of the key contacts for all IIS vendors. CDC is partnering with HUD on this project; HUD has a contact list for all jurisdictional and CoC HMIS users, as well as points of contact at all HMIS vendors operating in the US. As the survey is a very brief multiple choice survey, the method will be cross-sectional across the groups of respondents. The brief survey will be distributed to all individuals on these lists of users and vendors for voluntary participation. The explanatory text which will be sent in the email (included in packet) requests that “Only one person from each jurisdiction or vendor organization receiving this invitation should respond to the survey.” The number of respondents in the Burden Hours table reflects respondents if there is full participation by all organizations and jurisdictions.

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.

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