NIMH and NIMHD Virtual Disparities Workshop

Request for Approval under the “Conference, Meeting, Workshop, and Poster Session Registration Generic Clearance (OD)”

(OMB#: 0925-0740 Exp Date: 07/2022)

TITLE OF INFORMATION COLLECTION:

NIMH and NIMHD Virtual Workshop on Mental Health Disparities Registration

PURPOSE:

Collect preliminary information from participants in the NIMH and NIMHD Virtual Workshop on Mental Health Disparities.

DESCRIPTION OF RESPONDENTS:

Participants of the workshop include community, academic and federal researchers in the field of mental health disparities.

TYPE OF COLLECTION: (Check all that applies)

[ ] Abstract [ ] Application

[X] 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: Sandra Molina, NIMH

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [X] Yes [ ] No

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

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 COSTS

Category of Respondent	No. of Respondents	No. of Responses per Respondent	Time per Response (in hours)	Total Burden Hours
Private Sector	300	1	1/60	5
Totals		300		5

Category of Respondent	Total Burden Hours	Wage Rate*	Total Burden Cost
Private Sector	5	$41.29/hr	$206
Totals			$206

* Private sector and government respondent wage rate data is from the Life Scientists, All Other (19-1099) category at http://www.bls.gov/oes/current/oes_nat.htm#00-0000.

FEDERAL COST: The estimated annual cost to the Federal government is $ 123

Staff	Grade/Step	Salary*	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Health Scientist Administrator	13/7	$123,198	.1		$123
Contractor Cost
Travel
Other Cost
Total					$123

*the Salary in table above is cited from https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2020/DCB.pdf.

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 [X] 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?

We will send an email announcement about the workshop (with registration link) to NIMH and NIMHD listservs of employees and encourage them to forward as well. The workshop is open to the public so anyone who completes the registration form will be able to participate as an attendee, capacity permitting. Registrations are considered on a first-come, first-served basis until the virtual workshop reaches capacity.

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, facilitators, or research coordinators be used? [ ] Yes [X] No

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

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