Fast Track Template Provider Resources

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0653 Exp., date: 4/2018)

T ITLE OF INFORMATION COLLECTION: Online Survey: Pediatric Palliative Care Provider Resources

PURPOSE: The National Institute of Nursing Research (NINR) would like to deploy a brief, informal survey to get feedback from health care providers who care for children with serious illnesses. We would like to hear from health care providers about how best to disseminate the Palliative Care: Conversations Matter® campaign information among their colleagues. Receiving direct feedback will help NINR better meet the needs of providers and will guide campaign dissemination efforts. NINR is specifically interested in whether the development of a provider toolkit would be useful.

The survey will consist of 4 questions and take 5 minutes or less to complete. OCPL will not collect or save any identifying information, therefore the responses would be anonymous.

DESCRIPTION OF RESPONDENTS: Health care providers who care for children with serious illnesses. Respondents would consist primarily of those who are already familiar with NINR and the Palliative Care: Conversations Matter® campaign.

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:_ Adrienne Burroughs, MHS, Health Communications Specialist, NINR

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 - Health Care Providers/ Nurses	40	1	5/60	3
Totals	40			3

Category of Respondent	Total Burden Hours	Hourly Wage Rate*	Total Burden Cost
Individuals - Health Care Providers/ Nurses*	3	$32.91	$98.73
Totals	3	$32.91	$98.73

* Source: https://www.bls.gov/ooh/healthcare/registered-nurses.htm

FEDERAL COST: The estimated annual cost to the Federal government is $2,211. There is no cost associated with the survey platform. There are no respondent incentives. The estimated cost of labor to the federal government is $2,211, which includes survey development and administration, outreach to potential respondents, and compilation of results.

Staff	Grade/Step	Salary	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Health Communication Specialist	13/6	$110,595	2%		$2,211
Contractor Cost					N/A
Travel					N/A
Other Cost					N/A
Total					$2,211

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?

Respondents will consist of pediatric palliative care health care providers across the country. Potential respondents will be reached by tapping into existing provider networks and children’s hospitals will be encouraged to share the survey link with their staffs. This outreach will include connecting with contacts involved in earlier phases of the campaign.

Because of the narrow target audience, respondents will not be formally selected nor screened out. The first 40 responses to the survey will be accepted. Please see Appendix B: Outreach Language for sample communications to promote 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 (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.

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