Fast Track Template ODS Survey Request for Approval _ March_ 20_ 2012

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

(OMB Control Number: 0925-0648; Expiration date: 01/31/2015)

T ITLE OF INFORMATION COLLECTION: ODS Dietary Supplement Research Practicum Participant Survey

PURPOSE:

To determine in what ways attendance at the ODS Dietary Supplement Research Practicum has contributed to research, clinical practice, and education on dietary supplements at the participants’ place of work.

The information gathered from this survey will be used to inform any modifications and improvements made to the ODS practicum taking place in future years.

DESCRIPTION OF RESPONDENTS:

Individuals who have participated in ODS Dietary Supplement Research Practicum during one of the past five years (2007-2001).

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: Paul M. Coates, Ph.D.

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [X] Yes [ ] No

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

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals	381	25 minutes	9525 minutes
Totals			158.75hours

FEDERAL COST: The estimated annual cost to the Federal government is $40,000.

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? [ 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?

All those who have participated in the ODS practicum during one of the past five years (and for whom we were able to get an up-to-date email address) will be asked to take the online survey.

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.

We have attached the following:

• Email letter introducing the survey and requesting participation (as a screen shot)

• Screen shots of the survey in Survey Monkey

• Survey as a Word document

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