Fast track for EHD Workshop feedback

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0648 Exp Date: 06/31/2024)

TITLE OF INFORMATION COLLECTION: Environmental Health Disparities and Women’s Reproductive Health Workshop Survey (NIEHS)

PURPOSE:

Routine customer feedback survey for workshop on Environmental Health Disparities and Women’s Reproductive Health

DESCRIPTION OF RESPONDENTS:

Researchers, clinicians, and members of the community.

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: Darlene Dixon

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? [ 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

ESTIMATED BURDEN HOURS and COSTS

Survey	Category of Respondent	No. of Respondents	No. of Responses per Respondent	Time per Response (in hours)	Total Burden Hours
Survey	Individuals	500	2	2/60	33
Total		500	1000		33

COST TO RESPONDENT

Survey	Category of Respondent	Total Burden Hours	Hourly Wage Rate*	Total Burden Cost
Survey	Individuals	33	$38.81	$1,280.73
Total	Total			$1,280.73

*Cite source per bls.gov if applicable http://www.bls.gov/oes/current/oes_stru.htm#19-0000

FEDERAL COST: The estimated annual cost to the Federal government is $421.19

Staff	Grade/Step	Salary*	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight	GS12-8	$84,238	.05		$421.19
Contractor Cost
Travel
Other Cost
Total					$421.19

*Salary in table above is cited https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/2022/general-schedule/

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, provide a description of both below or attach the sampling plan.

The survey respondent can voluntarily answer survey questions from a SurveyMonkey automatic redirect from Zoom.gov that populates when workshop participant leaves the 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

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