LRP Ambassador OMB Clearance Form

Request for Approval under the “Conference, Meeting, Workshop, and Poster Session Registration Generic Clearance (OD)”

(OMB#: 0925-0740 Exp Date: 05/2019)

T ITLE OF INFORMATION COLLECTION: LRP Ambassador Sign-up and Consent

PURPOSE: To register individuals who choose to become Ambassadors for the Loan Repayment Programs (LRP) at the National Institutes of Health (NIH), and to record their consent to share their personal identifying information on the Ambassadors web page of the LRP website. LRP Ambassadors are primarily early career investigators who receive an LRP award and who agree to provide outreach about the LRPs to potential applicants (e.g., post-doctorates) at their institutions. The information collected from Ambassadors who agree that their personal information may be shared will be compiled into a directory to assist potential applicants in finding an Ambassador to talk with about the Loan Repayment Programs.

DESCRIPTION OF RESPONDENTS: There are approximately 7500 early career investigators who received an LRP award between 2011-2015. They will be sent an email invitation to become LRP Ambassadors. Those who wish to do so will be asked to complete the online sign-up form for which clearance is being sought. In addition, there are approximately 300 individuals who received an LRP prior to 2011, previously agreed to serve as Ambassadors, and reconfirmed their interest in 2016 via email, who will also be asked to complete the sign-up form.

Each year, approximately 1500 early career investigators receive an LRP award. An invitation will be extended to them to become Ambassadors for the program in the future. If they accept the invitation, they will also complete the form in order to be registered as Ambassadors.

TYPE OF COLLECTION: (Check one)

[ ] Abstract [ ] Application

[ x] Registration Form [ ] 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.

Name:____ Ericka Boone, Ph.D._________________________________________

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ x ] Yes [ ] No

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ x] Yes [ ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [ x ] No

Amount: ___________

Explanation for incentive: (include number of visits, etc.)

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	1500	1	5/60	125
Totals	1500			125

Category of Respondent	Total Burden Hours	Wage Rate*	Total Burden Cost
Individuals	125	$39.54*	$4942.50
Totals	125		$4942.50

* Median Pay for Medical Scientists per BLS Occupational Handbook (http://www.bls.gov/ooh/life-physical-and-social-science/medical-scientists.htm)

FEDERAL COST: The estimated annual cost to the Federal government is ______________________________________________________________$26,750.00______

Staff	Grade/Step	Salary	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Ericka Boone	15-1	$175,000	5		$8,750
Contractor Cost
One Contractor	n/a	$180,000	10		$18,000
Travel					none
Other Cost					none

The selection of 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?

The potential group of respondents is composed of individuals who received an NIH Loan Repayment award between 2003 and the present. All awardees will be invited to participate as LRP Ambassadors.

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

[ ] Survey form

[ ] Chart Abstraction

[ ] Other, Explain

2. Will interviewers, facilitators, or research coordinators be used? [ ] Yes [ x ] No

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

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