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:   
NIH Sexual & Gender Minority (SGM) Health Summer Intensive Series Customer Feedback -Final Session

PURPOSE:  
The Sexual & Gender Minority Research Office (SGMRO) wishes to collect feedback from participants of the NIH Sexual & Gender Minority Health Summer Intensive Series (SGM SIS). The goal of the SGM SIS is to enhance the learning of trainees about SGM health research and its intersection with science, policy, communication, and community engagement. For the final session, SGMRO would like feedback on the final session and the overall series. The SGM SIS participants will include summer interns, postbacs, predocs, postdocs, and NIH staff, who are interested in SGM health. The responses will be used to improve and expand the program for future participants.  

DESCRIPTION OF RESPONDENTS: 
Respondents are participants of the SGM SIS, which includes summer interns, postbacs, predocs, postdocs – who are trainees at the NIH Intramural Research Program and extramural academic institutions, as well as NIH staff. 

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: ______________________		

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:_ Irene Avila, PhD ([email protected]; 301-594-9701)

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  [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
50
1
10/60
8





Totals

50

8

COST TO RESPONDENT

 Category of Respondent

Total Burden
Hours
Hourly Wage Rate*
Total Burden Cost 
Individuals
8
$51
$408




Totals


$408
* https://www.bls.gov/oes/current/oes_47900.htm#19-0000

FEDERAL COST:  The estimated annual cost to the Federal government is ___$488
                         

 Staff

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





Assistant Director 
GS-15-2
$155,886
0.15%

$234
Program Officer 
GS-13-5
$126,949
0.2%

$254






Contractor Cost











Travel





Other Cost











Total




$488
*the Salary in table above is cited from https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/2023/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, 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 SGMRO will send an email to session participants who registered to complete the electronic feedback form at the end of each session. We expect approximately 50 trainees to register for the SGM SIS. Thus, we expect approximately 50 respondents.


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.