Request for Approval

Attachment G. Request for Approval under Generic Clearance for CASPER Data Collections

REQUEST FOR APPROVAL UNDER THE GENERIC CLEARANCE FOR COMMUNITY ASSESSMENT FOR PUBLIC HEALTH EMERGENCY RESPONSE (CASPER) DATA COLLECTIONS (0920-XXXX)

Instruction: This form should be completed by the primary contact person from the CDC CIO that will be sponsoring the investigation.

DETERMINE IF YOUR INVESTIGATION IS APPROPRIATE FOR THIS GENERIC CLEARANCE MECHANISM: Instruction: Before completing and submitting this form, determine first if the proposed investigation is appropriate for the CASPER Generic ICR mechanism. Complete the checklist below. If you select “yes” to all criteria below, the CASPER Generic ICR mechanism can be used.

Criteria

Request is for a Community Assessment for Public Health Emergency Response (CASPER).

[ ] Yes [ ] No

CASPER methodology (probability-based, two stage 30x7 cluster sampling methodology and administration of the questionnaire at the household level) for sample selection and data collection, or an approved alternative (e.g., oversampling, selecting more than 30 clusters, or census) will be utilized.

[ ] Yes [ ] No

CDC assistance is requested by one or more external partners (e.g., local, state, tribal, military, port, other federal agency, or international health authority or other partner organization).

[ ] Yes [ ] No

One or more CDC staff (including trainees and fellows) will be deployed to the field.

[ ] Yes [ ] No

Data collection will be completed in 180 days or less.

[ ] Yes [ ] No

The data collection instruments can and will be administered in-person.

[ ] Yes [ ] No

Did you select “Yes” to all criteria above?

If yes, the CASPER Generic Clearance ICR might be appropriate for your investigation. → You may proceed with this form.

If no, the CASPER Generic ICR is not appropriate for your investigation. → Stop completing this form now.

TITLE OF INFORMATION COLLECTION: Instruction: Provide the title of the investigation in the following format: [Reason for conducting CASPER (i.e., disaster emergency response/recovery, event responding to, follow up for a previous assessment)] — [City, State, Country], [Year]

DESCRIPTION OF THIS SPECIFIC COLLECTION

1. Problem to be Investigated: Instruction: Provide a summary of the event. The summary should include all the information you know at this time about the event. At a minimum, please provide the following information: 1) background necessary to understand the importance of the event; 2) justification of the need for an assessment, including a description of any data already available or data gaps that exist2) an explanation of how the information collected will be used to inform response, recovery, preparedness, or mitigation measures. Use as much space as necessary (suggested length: 250-500 words).

2. Characteristics of the Assessment:

[ ] 24 hour approval is requested for this assessment.

[ ] 72 hour approval is requested for this assessment.

[ ] Standard approval (within 5 business days) is requested for this assessment.

Instruction: If a 24- or 72-hour approval is requested, an explanation must be provided as to why it is needed. Specifically, CDC must make a case as to why collection must begin within 24 to 72 hours, and it must be related to a public health need.

3. Location of Assessment: Instruction: Indicate location where assessment will occur. If multiple locations, specify each one.

State:

City/County (if applicable):

Country:

4. Agency Requesting Assistance/Name and Position Title of Requestor:

Agency:

Name:

Position Title:

Note: Attach the Letter of Invitation requesting support. The letter should include the following information: 1) background on the event and 2) request for CDC assistance. Sensitive information in the Letter of Invitation not appropriate for public dissemination should be redacted.

5. Respondents: Instruction: Provide a brief description of your respondent population.

The respondent universe is comprised of any member of a household within the chosen geographic area of interest (sampling frame) who is aged 18 years or older.

Note: Define sampling frame.

6. Selection of Respondents: Instruction: Provide a brief description of how respondents will be identified and selected. Use as much space as necessary for the description.

Standard CASPER Selection Methodology

Other CASPER Selection Methodology

The preferred sampling method for CASPER is a probability-based, two stage cluster design (30x7 cluster sampling methodology). In the first stage of selection, 30 clusters (e.g., census blocks) within the sampling frame are selected, with their probability for being chosen proportional to the estimated number of housing units in each cluster. In the second stage, each trained, two-person interview team applies systematic random sampling to select seven housing units for the purpose of conducting interviews in each of the 30 clusters.

Please describe approved alterations (e.g., oversampling, selecting more than 30 clusters or census) in CASPER selection methodology used.

7. Data Collection Mode:

The survey methodology used for a CASPER lends itself to only one main mode of data collection, the in-person interview. Trained interview teams deploy into the field to select households within each cluster and obtain verbal consent from one resident aged 18 years or older in each selected household. After verbal consent is given, the interviewer reads the questions from the questionnaire aloud to the interviewee and records the interviewee’s responses on a paper (most common) or electronic form. The majority of questions are close-ended (e.g., yes/no, multiple choice), but a few are open-ended allowing for free text answers. The average length of an interview is 30 minutes. After returning from the field, data are entered into a database (Epi Info) for cleaning and analysis.

[ ] Questionnaire responses will be collected on paper forms.

[ ] Questionnaire responses will be collected on electronic forms (Please specify, e.g., laptops).

8. Type of Information to be Collected: Instruction: Please attach (draft) data collection forms (i.e., questionnaire).

9. Duration of Data Collection (number of days):

10. FEMA Coordination:

State Emergency Operations Center (EOC) is activated: [ ] Yes [ ] No

If yes, FEMA is involved in the disaster/emergency: [ ] Yes [ ] No

If yes, provide State public health department EOC liaison contact:

Name:

Title:

Contact:

INVESTIGATION LEAD: Instruction: Indicate the name, title, and affiliation of the person who will be leading the investigation.

Name:

Title:

Affiliation:

CDC SPONSORING PROGAM AND PRIMARY CONTACT PERSON: Instruction: Indicate the sponsoring CIO/Division/Branch for this investigation. Indicate the name, title, and contact information of the CDC Primary Contact Person for this investigation. Indicate the preferred method of contact during the OMB approval process. Note, contact person or a designee must be available during the OMB approval process in case questions arise.

CIO/Division/Branch:

Name of CDC Sponsoring Program Primary Contact Person:

Title of CDC Sponsoring Program Primary Contact Person:

Contact Information: Provide complete contact information. Check box for preferred method(s) of contact during the OMB approval process.

[ ] Office phone:

[ ] Home phone:

[ ] Cell phone/Blackberry:

[ ] E-mail:

[ ] Other:

CERTIFICATION: Please read the certification carefully. Type your name to validate that you are providing certification. Note: If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved. Certification should be signed by the CDC Primary Contact Person for this Investigation.

I, [INSERT NAME OF CDC SPONSORING PROGRAM CONTACT], certify the following to be true:

1. The collection is voluntary.

2. Respondents will not be personally identified in any published reports of the study.

3. Information gathered will be primarily used to inform effective response, recovery, preparedness, or mitigation measures.

4. No representative statistics will be collected.

CDC Sponsoring Program Primary Contact Name:

Date of Certification:

REQUESTED APPROVAL DATE (MM/DD/YYYY): Instruction: Indicate the date by which approval is needed.

DATE SUBMITTED TO INFORMATION COLLECTION REQUEST LIAISON (MM/DD/YYYY): Instruction: Please indicate the date the request is submitted to the ICRL.

E-mail the completed form to the Information Collection Request Liaison (ICRL), Stephanie I. Davis, at ncehomb@cdc.gov and sgd8@cdc.gov. If submitting outside business hours and immediate approval is needed, call 404-213-2967 to notify the ICRL of the submission.