COVID19 Vaccine Perception Surveys (CC)

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: COVID19 Vaccine Perception Surveys (CC)

PURPOSE: The purpose of this survey is to solicit feedback on the patient experience at the National Institutes of Health Clinical Center (NIHCC) vaccination clinic. We have ensured that these survey activities, which are designed to gather and measure customers’ perceptions of the quality of the Clinical Center’s services and operations, satisfy the requirements and the spirit of Executive Order (EO) 12862.

DESCRIPTION OF RESPONDENTS: A solicitation email will be sent with a web link to approximately 3,600 vaccine recipients.

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: Fred Vorck

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 [X] 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 Respondents	No. of Respondents	No. of Responses per Respondent	Time per Response Hours	Total Burden Hours
Individuals/household	3,600	1	5/60	300
Total		3600		300

COST TO RESPONDENT

Category of Respondent	Total Burden Hours	Hourly Wage Rate†	Total Burden Cost
Individuals/household	300	$25.72	$13,461
Total			$13,461

† https://www.bls.gov/oes/2019/May/oes_nat.htm#00-0000

FEDERAL COST: The estimated annual cost to the Federal government is $587

Staff	Grade / Step	Salary††	% of effort	Fringe if applicable	Total cost to government
Federal oversight
Privacy officer	13/6	$120,972	.4%		$484
Nurse Consultant	13/4	$114,059	.09%		$103
Contractor cost
Travel
Other cost
Total					$587

†† http://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/2021/locality-pay-area-definitions/

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?

Respondents will be vaccine recipients at the NIH use the Building 10 vaccination site. All recipients who have gone through the process will be invited to participate in a 3 question patient perception survey following their visit. This survey is voluntary and is called “Vaccine Survey for Patients.” Vaccine recipients will be sent a survey invitation after each vaccination per the two dose protocol associated with Pfizer and Moderna vaccines.

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

[ ] 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.