Fast Track ISCC Survey

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0642 Expiration Date: 03/31/2023)

TITLE OF INFORMATION COLLECTION:

Implementation Science Consortium in Cancer Survey Form

PURPOSE:

The purpose of this information collection is to gather input and feedback from the Implementation Science Consortium in Cancer stakeholder to help identify and vote on topics that should be addressed during the September 2020 meeting.

Questions regarding race and gender are asked for tracking purposes only – these categories are not mandatory fields, as indicated on the application form.

DESCRIPTION OF RESPONDENTS:

Scientists, Researchers, and PIs

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 Bernal

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, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [X] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? N/A

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 COST

Category of Respondent	No. of Respondents	No. of Responses per Respondent	Time per Response (in hours)	Total Burden Hours
Individuals	200	1	5/60	17
Totals		200		17

Category of Respondent	Total Burden Hours	Wage Rate*	Total Burden Cost
Individual	17	$46.95	$798.15
Totals			$798.15

* Averaged mean hourly wage rate for respondents based on BLS National Occupational Employment and Wage Estimates for Medical Scientist occupational code, 19-1040 and wage rate $46.95. https://www.bls.gov/oes/2019/May/oes_nat.htm#00-0000.

FEDERAL COST: The estimated annual cost to the Federal government is $3,243.03.

Staff	Grade/Step	Salary**	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Communications Manager	10/5	$74,303	1%		$743.03
Contractor Cost					$2,500
Travel					$0
Other Cost					$0
Total					$3,243.03

**The salary in the table above is cited from https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/20Tables/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

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? [ Y ] 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?

Respondents are those who attend DCCPS webinars and opt to complete the survey.

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 or facilitators be used? [ ] Yes [X] No