Fast-Track Template

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:

NIH/National Medical Association (NMA) Academic Career Development Workshop Contact Information and Feedback Form

PURPOSE:

To update contact information and obtain feedback from past recipients of the NIH/NMA Travel Awards program and past participants of the NIH/NMA Academic Career Development Workshop. The information will be used to update internal databases to outreach for potential future NIH-sponsored conferences, meetings, workshops, poster sessions, presentations, and panels.

DESCRIPTION OF RESPONDENTS:

Respondents are past recipients of the NIH/NMA Travel Awards program and past participants of the NIH/NMA Academic Career Development Workshop.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [X] Other: _Customer Feedback

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: Katrina Serrano, PhD, 301-480-7855.

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

3. If Applicable, has a System or Records Notice been published? [ Y ] 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	1000	1	5/60	83
Totals		1000		83

Category of Respondent	Total Burden Hours	Wage Rate*	Total Burden Cost
Individuals	83	$46.36	$3,847.88
Totals			$3,847.88

* The mean hourly wage for a past participant was calculated based upon the Occupation Code for Medical Scientist (19-1042), according to the Bureau of Labor and Statistics (https://www.bls.gov/oes/current/oes_stru.htm#19-0000).

FEDERAL COST: The estimated annual cost to the Federal government is $2,049.54.

Staff	Grade/Step	Salary**	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Health Scientist Administrator	13/2	$102,477	2%		$2,049.54
Contractor Cost
Travel
Other Cost
Total					$2,049.54

**The Salary in table above is cited from https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2019/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?

Respondents are past recipients of the NIH/NMA Travel Awards program and past participants of the NIH/NMA Academic Career Development Workshop.

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.

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