OER Survey fast track template

OER_Survey_Clearance (2).doc

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIH)

OER Survey fast track template

OMB: 0925-0648

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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0648 Exp., date: 03/2018)

T ITLE OF INFORMATION COLLECTION: OER Intercept Web Survey


PURPOSE:

The Office of Extramural Research (OER) will conduct a survey to provide the office with feedback on the effectiveness of the numerous services provided to our customers. The office will contact users of OER services and products to determine their needs and how the office can improve its services and products to better meet those needs. The survey is designed to ask questions concerning satisfaction with information, courtesy, accuracy and other similar aspects of the offices’ operations.


DESCRIPTION OF RESPONDENTS:

The respondents will be voluntary users of the OER website(s).



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:__David Rosen______________________________________________


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

Individuals and households

12,000

1

5/60

1000






Totals

12,000

12,000


1000



Category of Respondent


Total Burden

Hours

Hourly Wage Rate*

Total Burden Cost

Individual and households

1000

$24.73

$247.30





Totals



$247.30


*Cite source per bls.gov if applicable



FEDERAL COST: The estimated annual cost to the Federal government is_$56,340__


Staff


Grade/Step

Salary

% of Effort

Fringe (if applicable)

Total Cost to Gov’t

Federal Oversight






Branch Chief

15/8

134000

1%


$1,340













Contractor Cost





$55,000







Travel






Other Cost












Total





$56,340




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

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

  1. Will interviewers or facilitators be used? [ ] Yes [ X ] No


3

File Typeapplication/msword
File TitleGeneric Clearance Submission Template
SubjectGeneric Clearance Submission Template
AuthorOD/USER
Last Modified BySYSTEM
File Modified2017-11-16
File Created2017-11-16

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