HDRI Sub-Study Template Assessment

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: Health Disparities Research Institute (HDRI) Course Assessment

PURPOSE: This collection of information is required as part of the assessment of NIMHD’s Health Disparities Research Institute that will take place from August 14-17, 2017. Participants will rate daily speakers and program activities. All responses are anonymous and participation is voluntary. Information obtained from this document will be used to plan future Health Disparities Research Institutes.

DESCRIPTION OF RESPONDENTS: Postdoctoral students, assistant professors, early career research investigators, and scientists engaged in minority health and health disparities research who were invited to participate in the Health Disparities Research Institute.

TYPE OF COLLECTION: (Check one)

[ ] Abstract [] Application:

[ ] Registration Form [X] Other: Course assessment

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: Joan Wasserman, DrPH

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

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	55	1	15/60	14
Totals		55		14

Category of Respondent	Total Burden Hours	Wage Rate*	Total Burden Cost
Individuals	14	$34.24**	$479.00
Totals			$479.00

*Cite source per bls.gov if applicable

**Life, Physical, and Social Science Occupations, Occupation code 19-0000, mean hourly wage: https://www.bls.gov/oes/current/oes_nat.htm#19-0000

FEDERAL COST: The estimated annual cost to the Federal government is $4778.50

Staff	Grade/Step	Salary	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Ligia Artiles	12-8	$95,570	5%		$4778.50
Contractor Cost
Travel
Other Cost
Totals					$4778.50

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? [X] Yes [] 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?

Individuals who have been selected to participate in the Health Disparities Research Institute will be the respondents. Fifty-five individuals were selected to participate in this year’s institute.

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.

3