Fast Track Wellness Survey

Request for Approval under the

“Generic Clearance for the Collection of Routine Customer Feedback”

(OMB#: 0925-0642, Expiration Date: 05/31/2020)

TITLE OF INFORMATION COLLECTION: Information Gathering for Employee Wellness Program Needs

PURPOSE:

The NCI at Frederick Occupational Health Service (OHS) Wellness mission is to encourage employee engagement in illness prevention, health maintenance and chronic health management. In order to better serve the NCI at Frederick employee community, OHS would like to send a short survey to staff to gain better insight into the types of programs employees would like to have and would participate in.

DESCRIPTION OF RESPONDENTS:

The respondents of the survey are the employees of the NCI at Frederick, both federal and contract employees. Both the federal and contract staff are supported by Occupational Health Services and would be the target audience for wellness activites and classes. It is important to get input from both sets of staff. Currently there are approximately 3000 total employees at the NCI at Frederick.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [ x] Other: Customer Input/Use Survey

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: Melissa Porter

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/household	3000	1	2/60	100
Totals	3000	3000		100

Category of Respondent	Total Burden Hours	Hourly Wage Rate*	Total Burden Cost
Individuals/households	100	$45.64	$4564.00
Total			$4,564.00

*Source of the mean Hourly Wage Rate is provided by the Bureau of Labor Statistics, Occupation title “Medical Scientists” 19-1040, https://www.bls.gov/oes/2017/May/oes_nat.htm#00-0000.

FEDERAL COST: The estimated annual cost to the Federal government is $4,413.28.

Staff	Grade/Step	Salary**	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Administrative Manager	14/8	$141,328.00	1%		$1,413.28
Contractor Cost					$3,000.00
Travel					$0
Other Cost					$0
Total					$4,413.28

**The salary in the table above is cited from https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/18Tables/html/DCB.aspx

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

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

Administration of the Instrument

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

[ x ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

Will interviewers or facilitators be used? [ ] Yes [ x ] No

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