National Institute of Mental Health (NIMH) Professional Coalition for Research Progress Meeting Assessment Form

Request for OMB Clearance - Collection of Routine Customer Feedback (NIMH Coalition Meeting).docx

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIH)

National Institute of Mental Health (NIMH) Professional Coalition for Research Progress Meeting Assessment Form

OMB: 0925-0648

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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0648 Expiration Date: 03/2018)

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TITLE OF INFORMATION COLLECTION:

National Institute of Mental Health (NIMH) Professional Coalition for Research Progress Meeting Assessment Form

PURPOSE:


To collect feedback from attendees of the NIMH Professional Coalition for Research Progress meeting to assess their satisfaction with the event and solicit ideas for improving subsequent meetings. NIMH convenes this meeting to share the latest research advances and related developments at NIMH, foster dialogue on the future path and directions of NIMH-funded research, and to encourage facilitated dialogue, networking, and interactions among stakeholders and NIMH leadership.



DESCRIPTION OF RESPONDENTS:


Respondents are senior leaders and representatives from national professional organizations with an interest in mental health research who are members of the NIMH Professional Coalition for Research Progress.



TYPE OF COLLECTION: (Check one)

Shape2 Shape3 Customer Comment Card/Complaint Form 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: Dr. Julie Mason, Deputy Director, OSPPC/NIMH





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

Shape6 Shape7 Personally Identifiable Information:

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


  1. Shape8 Shape9 If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? Yes No


  1. Shape10 Shape11 If applicable, has a System or Records Notice been published? Yes No


Gifts or Payments:

Shape12 Shape13 Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? Yes 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

Private Sector

65

1

2/60

2






Totals

65

1


2



Category of Respondent

Total Burden

Hours

Hourly Wage Rate*

Total Burden

Cost

Private Sector

2

$50.47/hour

$100.94





Totals



$100.94

*Cite source per bls.gov if applicable https://www.bls.gov/oes/2016/may/oes119199.htm


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

$1,319.00




Staff



Grade/Step



Salary


% of Effort

Fringe (if applicable)

Total Cost to Gov’t

Federal Oversight






Program Analyst

13/4

$106,668

0.6%


$640

Program Analyst

13/6

$113,132

0.6%


$679







Contractor Cost












Travel






Other Cost






Total





$1319.00




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

Shape14 Shape15 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 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 are members of the NIMH Professional Coalition for Research Progress with an interest in mental health research.



Administration of the Instrument

  1. Shape16 How will you collect the information? (Check all that apply) Web-based or other forms of Social Media Telephone

In-person Mail

Other, Explain Paper form distributed at the meeting


  1. Shape18 Shape17 Will interviewers or facilitators be used? Yes


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

Shape4 Shape5

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Last updated: August 2016


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleGeneric Clearance Submission Template
SubjectGeneric Clearance Submission Template
AuthorOD/USER
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