Fast-Track Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0648 Exp., date: 05/2021)

T ITLE OF INFORMATION COLLECTION: Overall Feedback Results for NIH Regional Seminar – Fall 2019

PURPOSE: The NIH Regional Seminar serves the NIH mission of providing education and training for the next generation of biomedical and behavioral scientists. This seminar is intended to demystify the application and review process, clarify federal regulations and policies, and highlight current areas of special interest or concern. The overall feedback form serves to collect feedback from seminar attendees on the seminar as a whole. Responses will be used to enhance the program for future participants.

Additional details on the NIH Regional Seminar may be found at: https://regionalseminars.od.nih.gov/phoenix2019/welcome/

DESCRIPTION OF RESPONDENTS: The NIH Office of Extramural Research wishes to collect feedback from attendees of the NIH Regional Seminar. Responses will be used to enhance the program for future participants.

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: Cynthia Dwyer, [email protected]

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	268	1	5/60	22
Totals	268	1	5/60	22

Category of Respondent	Total Burden Hours	Hourly Wage Rate*	Total Burden Cost
Individuals	22	$27.60	$607.20
Totals	22		$607.20

*https://www.bls.gov/news.release/empsit.t19.htm

FEDERAL COST: The estimated annual cost to the Federal government is __$11,128.92__________

Staff	Grade/Step	Salary*	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Federal Staff 1	GS 13/10	$128,920	0.10%		$128.92
Contractor Cost					$11,000**
Project Manager
Conference Team Manager
Travel
Other Cost
Total					$11,128.92

*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 NIH Regional Seminar Fall 2019 attendees will be asked to complete and submit the feedback form.

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

[X] In-person

[ ] Mail

[ ] Other, Explain

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

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

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