GenIC Request

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 0923-0047)
TITLE OF INFORMATION COLLECTION: National Environmental Public Health
Internship Program Survey
PURPOSE: The purpose of this data collection request is to collect feedback on the National
Environmental Public Health Internship Program. The Environmental Health Services Branch
within the National Center for Environmental Health has provided funding through a contract to
the National Environmental Health Association (NEHA) in support of a summer internship
program for college students interested in pursuing a career in environmental health. The
internship program supports participants as they complete a 10-week internship with state, tribal,
or local public health departments. The proposed information collection consists of a survey
designed to: 1) collect information about students’ experiences in the internship program; 2)
identify ways in which the internship program can be improved based on intern satisfaction; and
3) understand the program’s potential impact on the students’ future careers. Results of the
proposed information collection will be used to improve the administration of the internship
program. Respondents will participate in a 10-minute survey about their satisfaction and
experiences with the internship program. Participation will be completely voluntary.
DESCRIPTION OF RESPONDENTS: The online survey questionnaire (Attachment B and C)
will be offered to all 31 environmental health college students who participated in the National
Environmental Public Health Internship Program in 2015 and 2016.
TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software)
[ ] Focus Group

[ ] Customer Satisfaction Survey
[ ] Small Discussion Group
[X] Other: _Online Survey Questionnaire_

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.
Digitally signed by Alisha Etheredge -S
DN: c=US, o=U.S. Government, ou=HHS, ou=CDC, ou=People,
0.9.2342.19200300.100.1.1=1000311055, cn=Alisha Etheredge -S
Date: 2016.07.29 13:06:18 -04'00'

Alisha Etheredge -S
Name:________________________________________________
To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [X] No

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2. If Yes, is the information that will be collected included in records that are subject to the
Privacy Act of 1974? [ ] Yes [ ] 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

BURDEN HOURS
We expect a 100% response rate for the online survey (total of 31 respondents).
Participation
Burden
No. of
Respondents Time
31
10/60 5 hours

Category of Respondent
Student Interns

5 hours

Totals
FEDERAL COST: The estimated annual cost to the Federal government is approximately
$1260.

This cost reflects $240 for approximately 5 hours of salary (Commissioned Officer, O-5) for one
staff person to consult on design, implementation, and drafting an internal report of results. In
addition, the cost for the NEHA internship program coordinator to create and distribute the
survey and assist with analysis of results (est. 26 hours of salary) is approximately $1,020.
Therefore, the total estimated annual cost to the Federal government is $1260 ($240 + $1,020).
The annual cost associated with respondent burden hours is approximately $62 (determined
using an intern stipend of $500/week or $12.50/hour).
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 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?
The respondent universe will consist of the 31 students that have participated in the National
Environmental Public Health Internship Program in 2015 and 2016. A list of their email
addresses already exists and will be used to disseminate the survey. All potential
respondents will be sent a recruitment email (Attachment A) with a link to the online survey
for intern participants. No personally identifiable information will be collected.

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Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[X] Web-based or other forms of Social Media
NCEH and NEHA will use SurveyMonkey® to collect the online survey responses. The
use of SurveyMonkey® has been reviewed and approved to be compliant with HHS IT
security standards. An IT security plan is in place for this application.
[
[
[
[

] 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.
The following attachments are included:
Attachment A - Email Invite for the NEPHIP Survey
Attachment B - NEPHIP Survey (text)
Attachment C - NEPHIP Survey (online)

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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.
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.
No. of Respondents: Provide an estimate of the Number of respondents.
Participation Time: Provide an estimate of the amount of time 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 responses and the
participation time and 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.
Please make sure that all instruments, instructions, and scripts are submitted with the
request.

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