Fast Track PRA Submission Short Form

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Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery” (OMB Control Number: 0935-0179)
TITLE OF INFORMATION COLLECTION:  Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division

PURPOSE:  

This collection is used to obtain feedback from stakeholders who participated in or engaged with Evidence-based Practice Center (EPC) evidence reviews. The information will be used for internal quality improvement to assess stakeholder engagement processes, communication, and overall satisfaction, and to identify opportunities for improving future EPC products and interactions.



DESCRIPTION OF RESPONDENTS: 

Respondents include stakeholders who have participated in EPC evidence reviews, such as federal agency representatives, partner organizations, and other individuals with direct experience engaging with the EPC program.



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:______ Angela Carr, DSocSci, MHA, RN____________________________________
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 [X  ] 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 AND COST

Category of Respondent
No. of Respondents
Participation Time in Hours
Burden
Cost
Customers/Partners
25
0.25
6.25
$702.25
Totals




*Occupational Employment Statistics, May 2025 National Occupational Employment and Wage Estimates United States, U.S. Department of Labor, Bureau of Labor Statistics mean wage for 19-1042 Medical Scientists-http://www.bls.gov/oes/current/oes_nat.htm#b29-0000
The Adjusted Hourly Rate was estimated at 200% of the hourly wage.

FEDERAL COST: The total estimated annual cost to the Federal government is $2,334.
AHRQ Position
Hours
Adjusted Hourly Rate**
Annual Cost
Project Manager
20
$116.7
$2,334
2026 General Schedule Pay Schedule for Washington, DC Area Salary Table 2026 for GS13/1 https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/26Tables/html/DCB.aspx 
The Adjusted Hourly Rate was estimated at 200% of the hourly wage.

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?											[ ] Yes	[ X] 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?

AHRQ does not maintain a fixed or pre-defined customer list in advance of each collection. Respondents are identified on a rolling basis from individuals and organizations that partner with the EPC program throughout the year on evidence reviews (e.g., engaged stakeholders).

Following the completion of each evidence review, all eligible partners who participated in that specific review are invited to complete the survey. As such, this is not a sampled population but rather a census of participants associated with each individual review.


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 
[  X] Other, Explain 
In some cases, brief follow-up virtual meetings may be conducted with select respondents to clarify survey responses or explore outstanding questions or concerns in greater detail. These discussions are informal, limited in scope, and used solely to support internal quality improvement efforts.

1.a. Percentage reporting electronically [ 100%]

    2. Will interviewers or facilitators be used?  [X  ] Yes [  ] No
 
Please make sure that all instruments, instructions, and scripts are submitted with the request.
Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” 

TITLE OF INFORMATION COLLECTION:  Provide the name of the collection that is the subject of the request. (e.g.  Comment card for soliciting feedback on xxxx)

PURPOSE:  Provide a brief description of the purpose of this collection and how it will be used.  If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information.  These groups must have experience with the program.

TYPE OF COLLECTION: Check one box.  If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION:  Please read the certification carefully.  If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information:  Provide answers to the questions.  Note:  Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

Gifts or Payments:  If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:
Category of Respondents:  Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households; (2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government.  Only one type of respondent can be selected per row. 
No. of Respondents:  Provide an estimate of the Number of Respondents.
Participation Time:  Provide an estimate of the amount of time (in minutes) required for a respondent to participate (e.g. fill out a survey or participate in a focus group)
Burden:  Provide the Annual burden hours:  Multiply the Number of Respondents by the time in hours.
Cost: Provide the estimated cost for burden hours based on the wage used for the target audience. 

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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.  Please provide a description of how you plan to identify your potential group of respondents and how you will select them.  If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument:  Identify how the information will be collected.  More than one box may be checked.  Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Submit all instruments, instructions, and scripts with the request.