Conference Registration Template

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

(OMB#: 0925-0740 Exp Date: 7/2022)

TITLE OF INFORMATION COLLECTION: ORWH Course Registration Form

PURPOSE: The Office of Research on Women’s Health is releasing a series of interprofessional education courses. The courses are intended for researchers, clinicians, graduate students, and health professionals. This registration form will be used for ORWH interprofessional education courses, which currently include: “Bench to Bedside – Integrating Sex and Gender to Improve Health” and “Sex As a Biological Variable – A Primer.” The “ORWH Course Registration Form” will collect the following information from registrants:

• Contact information

• Basic demographic information

• Education history: degree(s) received, field(s) of study and year of degree

• Work sector (public, private, academic, other)

• Research career stage

The “ORWH Course Registration Form” will help ORWH characterize learners and identify opportunities for targeted outreach. The information will also be instructive as ORWH develops future course topics.

A PIA has been completed and approved for this information collection.

DESCRIPTION OF RESPONDENTS:

Anticipated respondents include:

• NIH staff and scientists

• FDA staff and scientists

• Extramural researchers and clinicians

• Students and faculty in medical, nursing, pharmacy, and other health-related professional schools and programs

• Researchers and clinicians in the pharmaceutical industry

• Allied health professionals

• Others with an interest in sex and gender differences in healthcare

TYPE OF COLLECTION: (Check one)

[ ] 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:____Margaret Bevans, Ph.D., RN, FAAN (3/18/2020)_______________________

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
Individuals	15	1	5/60	1
Private sector	25	1	5/60	2
Federal government	60	1	5/60	5
Totals		100		8

There are no costs to respondents other than their time.

Category of Respondent	Total Burden Hours	Wage Rate*	Total Burden Cost
General public	1	$24.98	$24.98
Health professionals	5	$39.42	$197.10
Health educators	2	$28.68	$57.36
Totals			$279.44

* Hourly wage rates are based on Bureau of Labor and Statistics tables (https://www.bls.gov/oes/current/oes_nat.htm). General public occupation title “All Occupations” code 00-0000. Health professionals occupation title “Healthcare Practitioners and Technical Occupations” code 29-0000. Health educators occupation title “Health Educators” code 21-1091.

FEDERAL COST: The estimated annual cost to the Federal government is $13,292.44

Staff	Grade/Step	Salary	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight	GS15/6	$166,487/year	0.5		$832.44
Contractor Cost
Contract scientist		$39.90	2	~	$1,660
Software system administrator – CIT					$10,800
Travel					$0
Other Cost					$0
Total cost					$13,292.44

*Cost to government is determined 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?

A course announcement will be circulated internally to NIH ICO partners and to the ORWH advisory committees. The announcement will be shared externally via stakeholder listservs, in the ORWH quarterly publication, and on the ORWH website. The FDA will send an announcement to internal listservs and advisory committees, announce on FDA OWH website, and share course announcement via internal newsletters.

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.