sub-study request for 2021 NCI -CONNECT Registration

Request for Approval under the Generic Clearance for the “Conference, Meeting, Workshop, and Poster Session Registration Generic Clearance (OD)”(OMB#: 0925-0740, Expiration Date: 07/31/2022)

TITLE OF INFORMATION COLLECTION: NCI-CONNECT Survivorship Workshop Registration (NCI)

PURPOSE:

The purpose of the collection is to have people who are attending our workshop register with their name, title, institution, phone, email and photo. We plan to use the information so we know participation numbers, to contact the registrants with information to join the virtual event and any necessary updates, and to create a program for the workshop.

DESCRIPTION OF RESPONDENTS:

The targeted group is health care professionals in neuro-oncology, including researchers, scientists, physicians, patients and community advocates. These are people who treat or support people with central nervous system cancers.

TYPE OF COLLECTION: (Check all that apply)

[ ] Abstract [ ] Application

[ X ] Registration Form [ ] 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.

Name: Dr. Terri Armstrong

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

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [ X ] No

Amount: _________

Explanation for incentive: (include number of visits, etc)

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	75	1	5/60	6
Totals		75		6

Category of Respondent	Total Burden Hours	Hourly Wage Rate*	Total Burden Cost
Individuals	6	$46.95	$281.70
Total			$281.70

*Source of the mean Hourly Wage Rate is provided by the Bureau of Labor Statistics, Occupation title “Medical Scientists” 19-1040, https://www.bls.gov/oes/2019/May/oes_nat.htm#00-0000.

FEDERAL COST: The estimated annual cost to the Federal government is $_4,593.

Staff	Grade/Step	Salary**	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Senior Branch Administrator	12/9	$109,362	1%		$1,093
Contractor Cost					$3,500
Travel					$
Other Cost					$
Total					$4,593

**The salary in the table above is cited from https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/21Tables/html/DCB.aspx

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential espondents 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?

We plan to invite neuro-oncology experts in survivorship care, neuro-oncologists and researchers. We are also invitee patient and community advocates. All invitees are from institutions across the nation. This group of respondents are colleagues we know in the field and in our collaboratice network of providers and health care professionals.

Administration of the Instrument

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

Will interviewers, facilitators, or research coordinators be used? [ ] Yes [X ] No

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

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