0955-0005_ONCCognitiveTestingFastTrackRequest6 10

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0955-0005)

T ITLE OF INFORMATION COLLECTION:

Cognitive Testing for Consumer Survey

PURPOSE:

The purpose of the cognitive testing is to obtain information about the processes people use to answer survey questions in a survey instrument currently under development by the Office of the National Coordinator for Health IT, as well as to identify any potential problems with the draft questions. The cognitive testing is designed to uncover difficulties in comprehension, wording, or reporting, and other potential issues, in both the English and Spanish versions of the instrument. This cognitive testing will also provide information on the average administration time of the draft survey in order to possibly eliminate items if needed. Following the completion of cognitive testing, any necessary changes to clarify wording and/or question intent will be incorporated into the draft survey instrument.

DESCRIPTION OF RESPONDENTS:

Adults: Cognitive testing will be conducted with as many as 25 adults (aged 18 years and older); the cognitive interviews are estimated to be 60 minutes in length, and will be conducted at NORC facilities in Chicago. Participants from different demographic segments will be recruited by a focus group facility in the Chicago area. The cognitive interviews will be conducted at NORC’s offices over the telephone, with the respondent and methodologist in separate rooms, in order to simulate the expected survey data collection mode.

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: _Cognitive Testing of Survey Instrument_____________________

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:___Penelope Hughes______________________________

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

Gifts or Payments:

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

As standard practice in commercial market research, cognitive testing participants will be offered an incentive at a regionally appropriate market rate, which is designed to defer travel costs and babysitting, etc. Participants in the cognitive testing conducted by NORC will receive no more than $40 for a cognitive interview, which is estimated to be 60 minutes in length.

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals (screening and recruitment)	25	.5	12.5
Individuals (participants)	25	1	25
Totals	25	1.5	37.5

FEDERAL COST: The estimated annual cost to the Federal government is $ 27,712.

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?

Participation in the survey will be voluntary. Participants from different demographic segments will be recruited by a focus group facility in the Chicago area. Professional recruiters from the facility will call potential participants from the existing opt-in database of local residents that they maintain. Interested participants will be assigned a unique numeric identifier and asked to schedule an in-person appointment at NORC’s offices.

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? [X] Yes [ ] No

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Submit all instruments, instructions, and scripts are submitted with the request.

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