Supporting Statement Part A

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0935-0179)

T ITLE OF INFORMATION COLLECTION: Nominator Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division

PURPOSE: The mission of the EPC program is to create reports that improve healthcare by supporting evidence-based decision making by patients, providers, and policymakers. To ensure that our reports are used, we invite nominations from professional organizations that create guidelines or other private or public sector organizations that need a systematic review of the evidence on some medical question in order to improve medical care. In order to improve how we work with these nominators and to improve the utility of the final report, we would like to interview a representative of each nominator (most likely whoever worked as liaison with us during the project) about their experience and the usefulness of the final report once the project is completed. This information will be used to increase the efficiency and impact of our program.

DESCRIPTION OF RESPONDENTS: Representatives of organizations that have nominated topics that were selected to become systematic reviews produced under contract by the EPC Program. The organization will choose which individual they feels can best represent the organization’s views.

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:_Elisabeth Kato__________

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, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) 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

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Representative of nominating organization	20	1 hour	20
Totals	20	-	20 hours

FEDERAL COST: The estimated annual cost to the Federal government is _$1,200_

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?

We have a list of all the organizations who have nominated topics and had their topic accepted for a systematic review and we intend to invite all of them to respond to the questions (100% sample).

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[x] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [x] Yes [ ] No

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