Information Collection

NIH Community-Based Participatory Research (CBPR) Grant Programs: Customer Satisfaction Surveys

IC 221145 under ICR 201412-0925-002 · OMB 0925-0474.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 NIH Community-Based Participatory Research (CBPR) Grant Programs: Customer Satisfaction Surveys	Form and Instruction
1 PI Satisfaction Survey Attachment A-CBPR PI Satisfaction Survey - screenshots 4-20-16.pdf	Form and Instruction
2 Grant PIs Satisfaction Survey Attachment B-Intervention Grant PIs Satisfaction Survey 4-18-16 - screenshots.pdf	Form and Instruction
3 Community Partners Satisfaction Survey Attachment C-CBPR Community Partners Satisfaction Survey screenshots 4-18-16 .pdf	Form and Instruction
CBPR-Mini Supporting Statement for CSR Generic Clearance 4_15_16.docx Mini SSA	IC Document
NIH OD SurveyGizmo for CBPR PIA.docx Privacy Impact Assessment	IC Document
Attachment D-Letter 1--OBSSR CBPR PI Customer Satisfaction Survey.docx E-mail Invitation	IC Document
Attachment E-Letter 2--OBSSR CBPR Community Partner Customer Satisfaction Survey.docx Email Invitation	IC Document
Attachment F-Letter 3--OBSSR Behavioral and Social Intervention Customer Satisfaction Survey.docx Email Invitation	IC Document
Attachment G-Letter 4--Madrillon Survey Gizmo Link Follow Up.docx Follow-up Email	IC Document
Attachment H-Letter 5--Madrillon Survey Gizmo Link Reminder.docx Email Reminder	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	PI Satisfaction Survey	Attachment A-CBPR PI Satisfaction Survey - screenshots 4-20-16.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2	Grant PIs Satisfaction Survey	Attachment B-Intervention Grant PIs Satisfaction Survey 4-18-16 - screenshots.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	3	Community Partners Satisfaction Survey	Attachment C-CBPR Community Partners Satisfaction Survey screenshots 4-18-16 .pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,050

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,050	1,050
Annual IC Time Burden (Hours)	353	353
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Mini SSA	CBPR-Mini Supporting Statement for CSR Generic Clearance 4_15_16.docx	04/20/2016
Privacy Impact Assessment	NIH OD SurveyGizmo for CBPR PIA.docx	04/20/2016
E-mail Invitation	Attachment D-Letter 1--OBSSR CBPR PI Customer Satisfaction Survey.docx	04/20/2016
Email Invitation	Attachment E-Letter 2--OBSSR CBPR Community Partner Customer Satisfaction Survey.docx	04/20/2016
Email Invitation	Attachment F-Letter 3--OBSSR Behavioral and Social Intervention Customer Satisfaction Survey.docx	04/20/2016
Follow-up Email	Attachment G-Letter 4--Madrillon Survey Gizmo Link Follow Up.docx	04/20/2016
Email Reminder	Attachment H-Letter 5--Madrillon Survey Gizmo Link Reminder.docx	04/20/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.