GenIC Request

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-0953)

T ITLE OF INFORMATION COLLECTION:

The World Trade Center (WTC) Health Program Call Center Satisfaction Survey

PURPOSE:

The WTC Health Program provides medical monitoring and treatment services to those directly affected by the September 11^th terrorist attacks at the WTC, the Pentagon, and in Shanksville, Pennsylvania. Currently, The WTC Health Program has over 70,000 members in every state of the nation. The Program was established by the James Zadroga 9/11 Health and Compensation Act of 2010 and is administered by The National Institute for Occupational Safety and Health (NIOSH) at the Centers for Disease Control and Prevention (CDC).

The Call Center for the WTC Health Program communicates directly with the public about a range of issues. Trained customer service representatives (CSR) assist current members with identifying appropriate Program resources. They help potential members with questions about applying to the Program. The Call Center also supports health professionals affiliated with the Program by clarifying relevant policies and procedures. The Call Center is also able to deliver services in Spanish, Polish, and Chinese.

NIOSH seeks to ensure that the WTC Health Program’s Call Center provides the highest quality service possible. We have created a customer satisfaction survey to track callers’ experience. Callers can choose to participate in this optional survey. If they opt to participate they will hear recorded questions. Responses will help us improve the Call Center experience.

DESCRIPTION OF RESPONDENTS:

Respondents will be a self-selected sample of individuals who have called the WTC Health Program’s Call Center. We anticipate that most of those who complete the survey will fall into one of the four categories:

• Current and eligible members—This group includes those who provided emergency response, recovery, and clean up services following the September 11^th terrorist attacks in New York, the Pentagon, and Shanksville, PA. It also includes those who were present in the dust cloud in New York on 9/11 and the days and weeks afterwards. Based on Call Center annual trends in call center usage, we expect the majority of respondents will be in this category. This group may also include members who wish to respond in Spanish, Polish, or Chinese.

• Clinical Center of Excellence staff—This group includes health care administrators and enrollment specialists at one of the Program’s New York based Clinical Centers of Excellence.

• Health Providers—This group includes physicians and other health professionals who are affiliated with the Program or are seeking to become affiliated with the Program.

• Pharmacy—This group includes pharmacists and other staff who assist members with their prescription needs.

TYPE OF COLLECTION: (Check one)

[ ] 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.

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: Laurie Breyer

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, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ X ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) 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	Number of Responses per Respondent	Participation Time per Survey	Total Burden Hours
WTC Health Program members/potential members	26,000	3	1/60	1,300 hours
Clinical Centers of Excellence	50	3	1/60	3 hours
Health providers	200	3	1/60	10 hours
Pharmacists	100	3	1/60	5 hours
Totals	26,350			1,318 hours

FEDERAL COST: The estimated annual cost to the Federal government is $26,000

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? [ ] Yes [ X] 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?

Participation in this survey will be self-selected among those who use the WTC Health Program’s Call Center. Respondents will not be recruited to participate.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ x ] Telephone—recorded selection

[ ] 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. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

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 per row.

No. of Respondents: Provide an estimate of the Number of Respondents.

Participation Time: Provide an estimate of the amount of time (in minutes) 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 Respondents and the Participation Time then 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.

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

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