Fast Track Cog Test Item Bank Request

Request for Approval under the

“Generic Clearance for the Collection of Routine Customer Feedback” (NCI)

(OMB Control Number: 0925-0642-35, Expiration Date 9/30/2014)

T ITLE OF INFORMATION COLLECTION: Cognitive Interviewing for Item Bank Fields in a Computer Adaptive Testing Instrument

PURPOSE:

The NCI Fast Track submission that was recently approved titled “User Simulation Study for NIH-SSA Collaboration to Improve Disability Determination” is related to this study. The user simulation study looks at how to improve the utility/functionality issues of the Computer Adaptive Testing (CAT) prior to further instrument development.

This request is to further develop the instrument by conducting cognitive interviews. The cognitive interviews will be performed to test and refine the questions in the item bank for the CAT. The item bank is being developed in conjunction with an Inter Agency Agreement between the National Institutes of Health and the Social Security Administration. This cognitive testing will use a moderator’s guide to elicit problems in wording or to provide clarity and meaning to questions. Examples of such problems include questions that are interpreted differently from what the measure intended, ambiguity in response options or item content, or use of words that are potentially confusing to respondents. Cognitive interviews will also be used to examine differences in alternative forms of questions and the responses.

DESCRIPTION OF RESPONDENTS:

• Respondents will include:

  • Patients seen at rehabilitation clinics

  • Respondents who frequent websites that cater to persons with disabilities

• Respondents must be at least 21 years old and be able to read and understand English.

TYPE OF COLLECTION: (Check one)

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

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [X] Other: Testing to Refine Questions_

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: ________Diane Brandt________________________________________

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 [ ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No

NCI will receive a narrative summary report only. The names and contact information of the respondents will not be maintained after conclusion of cognitive testing.

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [X] Yes [ ] No

Volunteers will be offered $20 for their participation in a cognitive interview. This is standard practice for the conduct of cognitive interviews of this nature and duration and with a hard to reach respondent group, such as people who have disabilities.

BURDEN HOURS

Category of Respondent	Instrument	No. of Respondents	Participation Time (in hours)	Burden
Individuals	Consent Form	70	5/60	6
	Moderator’s Guide	70	1	70
Total				76

Total Burden Hours used for IC’s to date: 1867

Total Burden Hours Approved for IC’s under 0925-0642: 8750

Total Burden Hours currently requested: 76

FEDERAL COST: The estimated annual cost to the Federal government is __$ 7,000___

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

Cognitive interviews will be conducted with persons selected from target groups who are similar to those who may complete the CAT based instruments in the future. These participants will be recruited from rehabilitation clinics or websites that cater to persons with disabilities. Flyers will be displayed or seen by patients in the rehabilitation service provider offices. Additionally, the text from the flyer will be posted on websites that cater to those with disabilities.

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 (interviews can be conducted either by phone or in-person)

[X] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [X] Yes [ ] No

List of instruments, instructions, and scripts submitted with this request:

Attachment #1: Recruitment Flyer

Attachment #2: Questions/Items to be Tested

Attachment #3: Cognitive Interview Moderator’s Guide

Attachment #4: Consent Form

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