fast track study for Sickle Cell Interest survey

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

TITLE OF INFORMATION COLLECTION: Sickle Cell Psychoeducation Support Group: Interest Survey (NHLBI)

PURPOSE: This is an interest Survey for the Sickle Cell Psychoeducation Support Group. The Sickle Cell Branch is starting a support group for patients with sickle cell disease. The group will be virtual, using video chat (Microsoft Teams). Each week a staff member would present on a topic related to living life with sickle cell disease and would then open the conversation up to the group members to talk about their experiences.

DESCRIPTION OF RESPONDENTS: Sickle Cell patients

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [X ] Other: Feedback/interest

FREQUENCY OF REPORTING: (Check one)

[x] Once [ ] Quarterly

[ ] Monthly [ ] On Occasion

[ ] Annually [ ] 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: __Kevin Purkiser

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 [X ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ X ] 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	20	1	5/60	2
Totals		20		2

Category of Respondent	Total Burden Hours	Hourly Wage Rate*	Total Burden Cost
Consumer/General Public	2	28.00	$56.00
Totals			$56.00

*Cite source per bls.gov if applicable or other source May 2021 National Occupational Employment and Wage Estimates (bls.gov)

FEDERAL COST: The estimated annual cost to the Federal government is __$204__________

Staff	Grade/Step	Salary*	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
CRTA Fellow		$68,000	.3%		$204
Contractor Cost
Travel
Other Cost
Total					$204

*the Salary in table above is cited from https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2022/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?

It will essentially be random. We are planning to offer the survey to whoever is scheduled to be seen in clinic in the 2-3 weeks after obtaining permission to distribute. We are trying to get an overall idea on what our patient population would like to go over during the support group meetings (if there is an interest in it at all).

To the question on how respondents will be recruited: it will be random. Whatever non-transplant sickle cell patients come in on our Monday & Thursday clinic days come in will be offered the opportunity to fill one out.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[X ] In-person Will be distributed by the RNs doing the patient’s vitals at clinic check-in. They will be asked NOT to put their name/identifying information on it. It will be returned to the team that way so feedback will be anonymous.

[ ] 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.

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