0990-Generic Clearance Submission_Provide servies for the Disseminationof CER survey supporting statement 9Nov2011

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

T ITLE OF INFORMATION COLLECTION:

Provide Services for the Dissemination of CER to Patients and Providers to Increase Adoption—Gutcheck Website Usability Survey

PURPOSE:

The project “Provide Services for the Dissemination of CER to Patients and Providers to Increase Adoption” is designed to strengthen the link between evidence production and strategies for conveying this information in ways that encourage evidence-based behavior change among providers and patients. The project team has created a suite of tools called Gutcheck to facilitate the dissemination and translation of comparative effectiveness research (CER) on colon cancer screening at the point of care.

The components of Gutcheck include:

• Gutcheck website

• Gutcheck Essentials—essential print components of the website

• DVD of videos on the website

• Posters

• T-shirts

• Bathroom decal

• Provider outreach email

• Provider outreach mailer

The website incorporates text content, videos, and visual graphics to translate evidence about colon cancer screening for consumers. Screenshots of all the website pages are available in Appendix A. The website can be viewed at http://gutcheck.nci.nih.gov/.

The purpose of this request is to obtain voluntary user feedback on the usability and design of the website. While visitors explore the website, they will be spontaneously asked if they would like to voluntarily complete a brief survey about the website (Appendix B).

DESCRIPTION OF RESPONDENTS:

The potential respondents are individuals who have access to the internet who self-select to go to the Gutcheck website. The website is open to everyone with internet access.

TYPE OF COLLECTION: (Check one)

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

[x ] 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: Pierre Yong

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 [ ] 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

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals	4750	3/60	238
Totals	4750	3/60	238

FEDERAL COST: The estimated annual cost to the Federal government is $500.00.

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?

The survey will be offered to visitors to the website. The survey is also available at any time by clicking on the survey tab. The website will also prompt the user to complete the survey at different intervals if the user has not already completed the survey or declined. The survey is voluntary, so respondents will be self-selected and respondents will not be identifiable.

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.

Attachments: Appendix A—Screenshots of the Gutcheck website

Appendix B—Gutcheck website usability survey

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