fast-track template NIDCD Inside Newsletter

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0925-0648)

T ITLE OF INFORMATION COLLECTION:

ONLINE SURVEY FOR NIDCD INSIDE NEWSLETTER

PURPOSE: To gather opinions and information about how the readers of NIDCD’s online newsletter, INSIDE, use the news and features found in the newsletter.

DESCRIPTION OF RESPONDENTS:

People who are currently subscribed for email notification of current issues of INSIDE.

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: Robin Latham_____________________________________________

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 [ ] 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
Individuals	284	15 minutes	71
Totals	284	15 minutes	71

FEDERAL COST: The estimated annual cost to the Federal government is $2,350.00

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 email addresses of individuals who subscribe to INSIDE. The list has 2,846 people on it. We will include a request to participate in the online survey with the next email announcement of the summer edition of INSIDE in June 2012. We estimate that 1/10^th of the people we ask will participate in the survey. We will be using Zoomerang as the platform for the survey. The survey instrument is attached.

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

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