Generic Clearance Submission Template

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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0643 Exp. Date: 10/31/2017)
TITLE OF INFORMATION COLLECTION:  Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Nurses’ Continuing Education Program on  Sudden Infant Death Syndrome (SIDS)—Customer Satisfaction Survey

	PURPOSE:  The Safe to Sleep® campaign (formerly Back to Sleep) was launched to raise the public’s awareness of ways to reduce the risk of Sudden Infant Death Syndrome (SIDS) and to help inform all parents and infant care givers about the importance of back sleeping.  The launch was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) in collaboration with the American Academy of Pediatrics (AAP), the SIDS Alliance (now First Candle/ SIDS Alliance), the Association of SIDS and Infant Mortality Programs (ASIP), and the Maternal and Child Health Bureau of the Health Resources Service Administration (HRSA).

Since the launch of the Safe to Sleep® campaign, NICHD has conducted the Nurse Continuing Education (CE) Program on SIDS Risk Reduction to educate nurses on safe sleeping and to help reduce the risk of SIDS.  The purpose of this data collection is to assess the nurses’ satisfaction with the program and their satisfaction with using the program materials and information in health care delivery settings.

DESCRIPTION OF RESPONDENTS: Nurses who completed the print or online version of the NICHD’s nurses’ CE program on SIDS risk reduction of the CE program between calendar years 2014 and 2015.


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: Jennifer Guimmond
	DHHS, NIH, NICHD


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  


ESTIMATED BURDEN HOURS and COSTS


Category of Respondent 
No. of Respondents
No. of Responses per Respondent 
Time per 
Response 
(in hours) 
Total Burden
Hours 
Private Sector
1,800
1
15/60
450





Totals
1,800
1
15/60
450


 Category of Respondent

Total Burden
Hours
Wage Rate*
Total Burden Cost 
Private Sector
450
$33.55
$15,097.50




Totals
450
$33.55
$15,097.50                                                     

*Bureau of Labor Statistics Registered Nurses http://www.bls.gov/oes/current/oes291141.htm#nat 

FEDERAL COST:  The estimated annual cost to the Federal government is $15,053.95.
                    
 Staff

Grade/Step
Salary
% of Effort
Fringe (if applicable)
Total Cost to Gov’t
Federal Oversight





NICHD Supervisor Project Oversight
GS 15-5
$143,079
0.05%

$7,153.95






Contractor Cost

$78,000
10%
 N/A
$7,800






Travel





Other Cost (Materials)




$100
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

The universe of potential respondents are nurses who completed the CE program between 2014-2015 and have a valid email address in the nurse CE program database.  There are approximately 6,000 nurses in the database and it is expected that at least 30 percent (1,800 respondents) will complete the 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.