OPP Annual Meeting Registration Form

Request for Approval under the “Conference, Meeting, Workshop, and Poster

Session Registration Generic Clearance (OD)”

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

TITLE OF INFORMATION COLLECTION:

National Institute of Mental Health (NIMH) Outreach Partnership Program Annual Meeting Registration Form

PURPOSE:

The NIMH Outreach Partnership Program is a nationwide initiative through which NIMH supports 55 Outreach Partners - primarily nonprofit mental health organizations representing every state, the District of Columbia, and Puerto Rico - to disseminate NIMH-supported research and educational resources through their mental health outreach and education activities. Attendance at an annual program meeting is required of all Outreach Partners. Registration data is collected to ensure smooth logistics, including travel support of sponsored participants.

DESCRIPTION OF RESPONDENTS:

Representatives of NIMH Outreach Partner organizations, mostly nonprofit mental health education and advocacy organizations that work at the state and local levels to educate the public and other key constituencies about mental health.

TYPE OF COLLECTION: (Check one)

☐Abstract ☐Application

☒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: Diana Morales, NIMH_______________________________________________

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? ☒Yes ☐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 ☒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
Private Sector - Sponsored Outreach Partner	55	1	10/60	9
Private Sector - Sponsored Non-Federal Presenter	5	1	10/60	1
Private Sector - National Partner & other Non-sponsored participants	7	1	5/60	1
Totals	90	90		11

Category of Respondent	Total Burden Hours	Wage Rate*	Total Burden Cost
Private Sector: Sponsored Outreach Partner	9	$28.68/hr	$258
Private Sector: Sponsored Non-Federal Presenter	1	$28.68/hr	$28
Private Sector: National Partner & other Non-sponsored participants	1	$105.95/hr	$106
Totals			$392

*Bureau of Labor Statistics May 2018 National Occupational Employment and Wage Estimates. Respondents wage rates reflect the mean hourly wage for Health Educators (21-1091) - https://www.bls.gov/oes/current/oes211091.htm, and Psychiatrists (29-1066) - https://www.bls.gov/oes/current/oes291066.htm.

FEDERAL COST: The estimated annual cost to the Federal government is: $3,241.50.

Staff	Grade/Step	Salary	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Public Health Analyst	GS-14/S 7	$58.31/hr	20 hrs		$1,166
Program Analyst	GS-13/S 10	$53.45/hr	10 hrs		$534.50
Contractor Cost		$4,200	25%	N/A	$1,050
Travel
Other Cost

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 ☐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 respondent list represents the contacts at 55 current Outreach Partner organizations and 8 invited presenters who are sponsored to participate in the meeting. In addition, respondents from National Partner organizations and select NIMH staff are invited, but not all attend.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

☒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 ☒No

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

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