Generic Clearance Submission Template

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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0668 Exp., date: 04/2022)
TITLE OF INFORMATION COLLECTION:  Survey for Soliciting Feedback on Safety Oversight Committee Training Program (NIAID)

PURPOSE:  


There are a limited number of experienced candidates available to serve on National Institute of Allergy and Infectious Diseases (NIAID) Division of Microbiology and Infectious Diseases (DMID) safety oversight committees. To recruit more experienced candidates, DMID’s Office of Clinical Research Affairs (OCRA) implemented a pilot safety oversight committee mentor program. To determine the feasibility of the mentor/mentee pilot program moving forward, a follow-up survey will be sent to the program participants following their completion of the activity.


DESCRIPTION OF RESPONDENTS: 

Experienced members (physicians) of safety oversight committees and physicians who were not previously familiar with the activities and responsibilities of such committees.


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: Sarah E. Miers________

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
24
1
15/60
6





Totals

24

6


 Category of Respondent

Total Burden
Hours
Hourly Wage Rate*
Total Burden Cost
Individuals
6
$24.34
$146.04




Totals
6

$146.04
* The Health Professionals wage rate was obtained from http://www.bls.gov/oes/2018/may/oes290000.htm
 Occupation title “Healthcare Practitioners and Technical Occupations”, occupation code 29-0000


FEDERAL COST:  The estimated annual cost to the Federal government is _$7885.45______
                         

 Staff

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

Federal Oversight






Nurse Consultant
GS14 step 10
$157,709
5%

$7885.45















Contractor Cost













Travel






Other Cost













Total




$7885.45

*the Salary in table above is cited from https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2018/DCB.pdf      


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?

All 24 program participants will be included in the survey. No sampling plan will be used.

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