Generic Clearance Submission Template

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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-Control #:  0925-0655 Exp Date: 04/2018) 
TITLE OF INFORMATION COLLECTION: Field Study of BH-Works™

PURPOSE:  To test the user experience and usefulness of BH-Works.  BH-Works is an online software application that identifies areas of mental health issues by using a scientifically developed and market-tested mental and behavioral health survey, in primary care, behavioral health, and substance abuse service sites. In this field study, information will be collected in two aspects from volunteer health professionals.  One, participants will test out BH-Works in different scenarios and give their feedback on its usefulness.  Two, a focus group session will be used to obtain qualitative feedback on the software and suggestions for additional software features.  No information on individual network members will be collected.

DESCRIPTION OF RESPONDENTS: Primarily clinicians and staff members at the primary care and mental health facilities, who will use BH-Works to administer the behavioral health survey.  Administrators may also participate.  

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form 	[ ] Customer Satisfaction Survey    
[Y] Usability Testing (e.g., Website or Software	[ ] Small Discussion Group
[Y] 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:(Name of NIDA Project Officer)__Belinda Sims______________

To assist review, please provide answers to the following question:

Personally Identifiable Information:
    1. Is personally identifiable information (PII) collected?  [ ] Yes  [N]  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 [N] 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 
Clinicians in primary care or mental health clinics responding to –

   Utility and Usability test

   Questionnaire Focus Group







25



1


10/60



4





1



1


25
Staff in primary care or mental health clinics responding to –

  Utility and Usability test

  Questionnaire Focus Group

  





25



1


10/60



4





1



1


25
Totals
50
100

58


 Category of Respondent

Total Burden
Hours
Wage Rate*
Total Burden Cost 
Clinicians
29
$37.40
$1,085
Staff Members
29
$37.40
$1,085
Totals
58

$2,170

*Cite source per bls.gov if applicable
 May 2015 National Occupational Employment and Wage Estimates United States http://www.bls.gov/oes/current/oes_nat.htm#29-0000



FEDERAL COST:  The estimated annual cost to the Federal government is $4,123.
                         

 Staff

Grade/Step
Salary
% of Effort
Fringe (if applicable)
Total Cost to Gov’t
Federal Oversight
GS14/10


$2,123

$141,555
1.5%

$2,123


















Contractor Cost

$100,000
2.0%

$2,000






Travel





Other Cost











Total 




$4,123



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	[N] 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?

We are identifying potential participants through existing relationships with health professionals, and selecting them based on their availability and interest. Two main relationships for this purpose are: 1) existing membership in the Black Mental Health Alliance, a mental health advocacy and referral hub organization in Baltimore area, and 2) existing relationships with Coppin State University academic and clinical personnel.


Administration of the Instrument
    1. How will you collect the information? (Check all that apply)
[Y] Web-based or other forms of Social Media 
[  ] Telephone	
[Y] In-person	
[  ] Mail 
[  ] Other, Explain

    2. Will interviewers or facilitators be used?  [Y] Yes [] No
 
The Usability and Utility Questionnaire will be administered as an anonymous web survey.
The Focus Group will be carried out in-person with facilitators.


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