Registration for the Advancing Environmental Health Equity through Implementation Science Workshop

Request for Approval under the “Conference, Meeting, Workshop, and Poster Session Registration Generic Clearance (OD)”

(OMB#: 0925-0740 Exp Date: 07/2022)

T ITLE OF INFORMATION COLLECTION: Registration for the Advancing Environmental Health Equity through Implementation Science Workshop (NIEHS)

PURPOSE: The purpose of this form is to allow members of the public to register for the Advancing Environmental Health Equity through Implementation Science Workshop.

DESCRIPTION OF RESPONDENTS:

The respondents may be persons from academia, industry, other governmental organizations, nongovernmental organizations, media, public.

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:____ Lindsey Ann Martin, PhD _____________

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	500	1	2/60	17
Totals		500		17

COST TO RESPONDENT

Category of Respondent	Total Burden Hours	Hourly Wage Rate*	Total Burden Cost
Individuals	17	$38.73	$658.41
Totals			$658.41

*(https://www.bls.gov/ooh/education-training-and-library/postsecondary-teachers.htm)

FEDERAL COST: The estimated annual cost to the Federal government is __$530.32

Staff	Grade/Step	Salary*	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight	12/8	$ 96,033	.1%		$96.03
Contractor Cost					$434.29
Travel
Other Cost
Total					$530.32

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

The workshop flyer will be distributed via email groups/listservs (see attached email script and draft event flyer). Within NIEHS various groups will be emailed the announcement (e.g., Environmental Health Disparities P50 Centers, Environmental Health Science Core P30 Centers, Superfund Research Program P42 Centers, Worker Education & Training Program, Partnerships for Environmental Public Health, Disaster Research Response Network, Global Environmental Health Program, NIEHS All Hands email, Environmental Health Disparities/Environmental Justice Faculty, NIEHS Diversity Supplement recipients, NIEHS Fellows and Trainees). Across NIH, various groups will be emailed the announcement (e.g., Behavioral and Social Sciences Research Coordinating Committee, Dissemination & Implementation Science Workgroup, Rural Health Special Interest Group, NIH wide email, Climate Change and Human Health Workgroup). Other HHS agencies will be sent the flyer as well (e.g., HHS Environmental Justice workgroup, contacts at CDC and EPA).

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

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