Template

Request for Approval under the “Generic Clearance for NIH Citizen Science and Crowdsourcing Projects”

(OMB#: 0925-0766 Exp., date: 09/2026)

TITLE OF INFORMATION COLLECTION: Self-Nomination Form for the NICHD OHE Internal Advisory Committee (NICHD)

PURPOSE:

The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Office of Health Equity (OHE) will invite self-nominations for membership on the Internal Advisory Committee. The committee will include ~ 15 representatives from across NICHD Intramural, Extramural and Office of the Director Divisions and will provide strategic recommendations on initiatives, programs, and strategies to NICHD leadership to advance the goals of diversity, equity, inclusion, and accessibility (DEIA). All staff, including FTEs, contractors, fellows and trainees will have the opportunity to submit a self-nomination form for consideration.  Information collected include name, position, previous experience, priorities, and reason for interest in participating in the OHE internal advisory committee.

INTENDED USE OF THIS INFORMATION:

The information gathered from this self-nomination form is for internal purposes only and will be reviewed by the NICHD OHE to help the selection of members/representatives for an Internal Advisory Committee.

DESCRIPTION OF RESPONDENTS:

The committee is internal to NICHD. Respondents will be NICHD staff, including FTEs, contractors, fellows and trainees. They will include various positions and career stages, as well as supervisory, and non-supervisory staff.

TYPE OF COLLECTION: (Check one)

[ ] Data Catalogue [ ] Repository of Tools and Best Practices

[ ] Recommendations of scientific reviewers [ ] Resources

[X ] Call for Nominations [ ] 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. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

5. 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: Parisa Parsafar

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

4. Privacy Act Systems of Records Title: 09-25-0156 Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service FR Citation _83___FR 6591

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	46	1	20/60	15
Totals		46		15

COST TO RESPONDENT

Category of Respondent	Total Burden Hours	Hourly Wage Rate*	Total Burden Cost
Individuals	15	$29.76	$446.40
Totals	15		$446.40

* Salary/Wage Source: Bureau of Labor Statistics/Occupational Employment and Wages, May 2022: Occupational Code 00-0000, All Occupations, national estimates, mean hourly wage: https://www.bls.gov/oes/current/oes_nat.html We used the all occupations average since respondents include a broad range of potential salaries/positions and we are unsure who might submit a self-nomination

FEDERAL COST: The estimated annual cost to the Federal government is __$1,411.92_________

Staff	Grade/Step	Salary*	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Social and Behavioral Scientist Administrator	14/3	141,192	1%		$1,411.92
Contractor Cost
Travel
Other Cost
Total					$1,411.92

*the Salary in table above is cited from https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2023/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 [ ] Not Applicable

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?

Sampling plan: Our NICHD Director, Deputy Director, Extramural Division Director, and Intramural Division Directors will be sending out the email solicitation for the self-nomination to the entire NICHD staff, including 916 trainees, fellows, and contractors. We anticipate a 5% response rate based on previous efforts to recruit volunteers for internal committees.

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.