Fast-Track Template

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

(OMB Control Number: 0925-0653 Expiration Date: March 31, 2015)

TITLE OF INFORMATION COLLECTION: Basic electronic survey to inform materials development for a pediatric palliative care communications campaign.

PURPOSE:

This is a request for OMB to approve an online survey instrument that will be conducted on behalf of the National Institute of Nursing Research (NINR), part of the National Institutes of Health (NIH), to inform its ongoing Palliative Care: Conversations Matter® campaign. The purpose of the campaign is to increase the use of palliative care for children living with serious illnesses. The proposed instrument will gather input on the information and materials that would be helpful to one of the campaign’s target audiences – parents and families of children with serious illnesses. Ultimately, the feedback received will inform the development of new communications products for the campaign.

DESCRIPTION OF RESPONDENTS:

The data collection process will include a total of one (1) online survey consisting of ten (10) questions. The target audience for this particular survey is parents and families of children with serious illnesses. There are no eligibility criteria regarding age of the child or respondent, type of illness, current health status, gender, ethnicity, geographic location, or respondent’s specific relationship to the child.

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: Rebecca Hawes, PhD, NINR PRA Liaison

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	Total
Individuals or Households	100	10/60	17 hours
Totals	100		17 hours

FEDERAL COST: The estimated annual cost to the Federal government is $3,204.45

There is no cost associated with the survey platform. There are no respondent incentives. The estimated cost of labor to the federal government is $3,204.45, which includes survey development and administration, outreach to potential respondents, and compilation of results.

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?

Administration of the Instrument

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

[x] Web-based or other forms of Social Media (surveymonkey.com no-cost tool with existing HHS federal-compatible terms of service agreement)

[ ] 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.

Appendix A: Feedback Instrument

Appendix B: Outreach Language

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