Generic Clearance Submission Template

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Request for Approval under the “Conference, Meeting, Workshop, and Poster Session Registration Generic Clearance (OD)” 
(OMB#: 0925-0740 Exp Date: 07/2022)
TITLE OF INFORMATION COLLECTION:  Challenges and Innovations in Neonatal and Infant Imaging Meeting Registration (NIMH)

PURPOSE:  
Collect preliminary information from participants of NIMH’s Challenges and Innovations in Neonatal and Infant Imaging Meeting about the successes and challenges in neonatal and infant imaging and provide resources and tools for researchers to push field towards greater harmonization, cohesiveness, and innovation.


DESCRIPTION OF RESPONDENTS: 
The meeting aims to bring together investigators who use fNIRS, EEG, MRI (structural, functional, and resting-state MRI, and DTI), MEG, and ultrasound imaging methods to study the neonatal and infant brain.

TYPE OF COLLECTION: (Check all that applies)

[ ] 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:	Janani Prabhakar and Taylor Gordon, NIMH


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/Households
500
1
1/60
8





Totals

500

8


Category of Respondent
Total Burden Hours
Wage Rate*
Total Burden Cost
Individuals/Households
8
$44.31
$354




Totals


$354
* Private sector and government respondent wage rate data is from the Life Scientists, All Other (19-1099) category at http://www.bls.gov/oes/current/oes_nat.htm#00-0000.

FEDERAL COST:  The estimated annual cost to the Federal government is $160.
                         
Staff
Grade/Step
Salary*
% of Effort
Fringe (if applicable)
Total Cost to Gov’t
Federal Oversight





Program Analyst
 GS-13/S 10
$134,798
0.05%

$53






Contractor Cost

$53.45/hour
2 hours

$107






Travel





Other Cost





Totals




$160
*the Salary in table above is cited from https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2021/DCB.pdf. 



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 send an email announcement about the meeting (with registration link) to NIMH listservs of employees and public partners, and encourage them to forward as well. We will also send an email announcement to listservs that have an audience of interest (e.g., conference listservs). The meeting is open to the public so anyone who completes the registration form will be able to attend and view the meeting via webcast.

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