0990-0379 Fast track form QHDO 6 4 12

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0990-0379)

T ITLE OF INFORMATION COLLECTION: Survey of Quick Health Data Online Users

PURPOSE:

To obtain feedback from users of the Office on Women’s Health’s Quick Health Data Online (QHDO) data system in order to assess the responsiveness of the system to user needs and to obtain information so that the system can be even more responsive to user needs in the future.

DESCRIPTION OF RESPONDENTS:

Among the QHDO users are public health professionals, health providers, academic researchers, students, and staff in insurance companies, private research organizations, advocacy organizations, state agencies, and federal agencies.

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: Judith Labiner-Wolfe, PhD

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 (hours)	Burden (hours
QHDO individual users	500	5/60	42 hours
Totals	500	5/60	42 hours

FEDERAL COST: The estimated annual cost to the Federal government is $10,000. This includes $5,000 in hours used by the contractor for QHDO (QRS, Inc.) to design the instrument, implement the data collection and tabulate the results and $5,000 in hours for federal staff to oversee the project and analyze the resulting data.

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?

Respondents will be invited to complete a survey in the following ways:

• A link will be provided on the QHDO website inviting users to complete the survey.

• Twice-monthly, on-line training sessions are conducted; at the conclusion of each session participants will be directed to the web-based survey and invited to complete it.

• Office on Women’s Health staff members routinely communicate with community entities that have been encouraged to use the system; the OWH Regional Women’s Health Coordinator’s will be asked to communicate with their constituents and invite them to complete the survey.

• OWH will have a contractor that assists in promoting the Office’s initiatives and programs – this contractor will be asked to promote the survey.

In all approaches, web-links will be provided so that interested parties can easily access the online survey.

Administration of the Instrument

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

[X] Web-based

[ ] 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.

We have attached screen shots with the skip logic added to them. In addition, the link to the draft survey can be accessed at: http://www.surveymonkey.com/s/YVWX6PX

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