Generic Clearance Submission Template

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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0648 Exp., date: 06/30/2024)
TITLE OF INFORMATION COLLECTION:  Honoring Health e-Newsletter Feedback

PURPOSE:  

The NIH Tribal Health Research Office (THRO) communications team wishes to gauge customer satisfaction with its email information and corresponding website for the Honoring Health e-newsletter publication. Honoring Health features a different health topic in each issue and highlights resources, events, training, and grants and funding opportunities.
This survey asks five close-ended questions to gain feedback on the helpfulness and overall satisfaction the Honoring Health e-newsletter. 
DESCRIPTION OF RESPONDENTS: 
Respondents are comprised of individuals who subscribe to the Honoring Health e-newsletter or visit the Honoring Health website and choose to voluntarily click on the survey link and respond. This includes members of the general public, Tribal communities, and other federal agencies.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form 	[X] 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:__Melody Delmar- Health Science Policy Analyst/THRO, Bonnie Tabasko- Communications Director/THRO___


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

Personally Identifiable Information:
    1. Is personally identifiable information (PII) collected?  [  ] Yes  [ X]  No 
    2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974?   [  ] Yes [  ] No   
    3. If Applicable, has a System or Records Notice been published?  [  ] 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/Households
250
1
1/60
4





Totals
250
250

4

COST TO RESPONDENT

 Category of Respondent

Total Burden
Hours
Hourly Wage Rate*
Total Burden Cost 
Individuals/Households
4
$27.07
$108.28




Totals


$108.28

*Mean hourly wage used for category 00-0000 https://www.bls.gov/oes/current/oes_nat.htm#00-0000.


FEDERAL COST:  The estimated annual cost to the Federal government is $597.48_____
                         

 Staff

Grade/Step
Salary*
% of Effort
Fringe (if applicable)
Total Cost to Gov’t
Federal Oversight





Program Analyst
13/1
$103,690
.05%

$51.85
Administrative Officer
11/1
$72,750
.75%

$545.63






Contractor Cost




0






Travel




0
Other Cost




0






Total




$597.48
*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      


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 those who already subscribe and receive the Honoring Health e-newsletter.  The survey will also be publicly available to those who visit the Honoring Health website repository.  

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.