Generic Clearance Submission Template

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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0648 ExpDate: 3/31/18)
TITLE OF INFORMATION COLLECTION:  

Division of Senior and Scientific Executive Management (DSSEM) Application and Interview Satisfaction Survey

PURPOSE: 
 
The purpose of the Division of Senior and Scientific Executive Management (DSSEM) Application and Interview Satisfaction Survey is to assess satisfaction of applicants who have applied to NIH’s senior and scientific executive positions.  Only those who have been interviewed will be given the survey.  The results of the survey will be used to improve the recruitment process.


DESCRIPTION OF RESPONDENTS: 

The target audience is job applicants who have been interviewed by the search committee.


TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form 	[X] Customer Satisfaction Survey    
[ ] Usability Testing (e.g., Website or Software	[ ] Small Discussion Group
[ ] 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:________ Sylvia Chen ____________________________

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
Interviewed Job Applicants (potentially non-federal employee)
50
1
5/60
4





Totals
50
50

4


 Category of Respondent

Total Burden
Hours
Hourly Wage Rate*
Total Burden Cost
Interviewed Job Applicants (potentially non-federal employee)
4
$23.65
$94.60




Totals
4 hours

$94.60
Bls.gov Occupational Employment and Wages, May 2015, Silver Spring-Frederick-Rockville, MD Metropolitan Division http://www.bls.gov/oes/current/oes_43524.htm#00-0000 


FEDERAL COST:  The estimated annual cost to the Federal government is $1,995.30.
                         

 Staff

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





Survey Team Member
GS 11/1
$66,510
3%

 $1,995.30












Contractor Cost











Travel





Other Cost











Total




$1,995.30



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?											[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?

Full census of interviewed job applicants.  Participation in the survey is voluntary.


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 
[  ] Other, Explain
    2. Will interviewers or facilitators be used?  [  ] Yes [X] No