Generic Clearance Submission Template

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

TITLE OF INFORMATION COLLECTION:  BRAIN Explorer Feedback Survey

PURPOSE:  The purpose of this survey is to receive feedback from the users of a web-based, interactive, educational experience called the BRAIN Explorer and their overall satisfaction with the web-based interactive program (e.g. topics covered, quality, enjoyment, etc.). These survey results will be used to inform the improvement of the BRAIN Explorer interactive experience.

DESCRIPTION OF RESPONDENTS: Respondents are users of the web-based interactive program, which can include, but are not limited to: high-school aged students, teachers, and other members of the public. It is a public webpage that anyone can access. 


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: Sophia Jeon, Ph.D. Health Science Policy Analyst, NINDS OSPP

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  [X] 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 
Individual: BRAIN Explorer Users
1000
1
1/60
17










Totals

1000

17


 Category of Respondent

Total Burden
Hours
Wage Rate*
Total Burden Cost 
Individual: BRAIN Explorer Users
17
$25.72
$437.24
Totals


$437.24
*Hourly wage rates for 00-0000 All Occupations avg is $25.72 (based on https://www.bls.gov/oes/current/oes_nat.htm#00-0000).   


FEDERAL COST:  The estimated annual cost to the Federal government is $19,642.25.
                         
 Staff

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





NINDS staff 1
14/4
$126,049
5%

$6302.45
NINDS staff 2
12/1
$83,398
10%

$8339.80






Contractor Cost (optional): 





NINDS staff 3

$100,000
5%

$5000.00






Travel (optional)





Other Cost (optional)





Total




$19,642.25

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 be distributing the web-based interactive experience for use during virtual educational events, such as the virtual US Science and Engineer Festival, public library programming, and to an association of professional science teachers as potential supplemental material for their curriculum. The respondents could include students, teachers, facilitators/outreach organizers, and parents/guardians.

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