Fast Track CCLF Request

Request for Approval under the

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

(OMB Control Number: 0925-0642-38, Expiration Date 9/30/2014)

TITLE OF INFORMATION COLLECTION: The Cancer Control Leadership Forum Delivery Satisfaction Survey

PURPOSE: The National Cancer Institute’s Center for Global Health (CGH) is holding a series of Cancer Control Leadership Forum Workshops to increase the capacity of participating countries to initiate or enhance cancer control planning and implementation in their respective countries. Forums are opportunities for countries to exchange experiences and develop action plans around creating and implementing comprehensive cancer control plans. The Forums are two to three day meetings with large group presentations and interactive discussions, along with facilitated discussions and action planning sessions. The information provided by these surveys will determine if the immediate objectives of the workshop were met, and what changes can be made, if any, to improve the delivery of information.

DESCRIPTION OF RESPONDENTS: Participants of the Cancer Control Leadership Forum will include individuals from foreign government agencies, professionals from cancer societies and other cancer professionals working on cancer control planning and implementation activities.

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: Brenda Kostelecky, Ph.D.

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

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	84	10/60	14

Total Burden Hours used for IC’s to date: 2043

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

Total Burden Hours currently requested: 14

FEDERAL COST: The estimated annual cost to the Federal government is $140

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

Respondents are leaders in cancer control planning and implementation in their respective countries and are selected by the foreign government to attend the Cancer Control Leadership Forum Workshop. Workshop faculty will read a short invitation to the respondents (Attachment 2) and then hand out the surveys (Attachment 1).

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[X] In-person

[ ] Mail

[ ] Other, Explain

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

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

Attachment #1: Survey

Attachment #2: Invitation

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