KAI for PROMIS Survey OMB Form_FINAL (2)

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

Expiration Date: 01/2015

T ITLE OF INFORMATION COLLECTION: Semi-structured telephone interview for end users who are stakeholders in PROMIS.

PURPOSE: KAI, as a contractor to the NIAMS, proposes to conduct one time telephone interviews with end users of the PROMIS measures. This interview is a part of a mid-course evaluation KAI is coordinating for the NIAMS. The results (in aggregate) from this survey will be used by an independent review panel to help in conducting an evaluation of the PROMIS project.

DESCRIPTION OF RESPONDENTS: For the NIAMS contract, KAI proposes conducting a one time telephone interview to approximately 15 end users. End users are defined as clinical investigators, public health researchers, and industry researchers who have used the PROMIS measures in their work.

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:_____Randi M. Williams, M.P.H.__________________________

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

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals	15	40 minutes	10
Totals	15	40 minutes	10

FEDERAL COST: The estimated annual cost to the Federal government is _$150.00_____

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?

A list of potential Semi-structured interview participants will be provided by the NIAMS. KAI will use a snowball sampling method by collecting names of possible interviewees from those that are initially reached. Written letters and confidentiality/conflict of interest statements will be mailed to invite each individual to participate in a semi-structured telephone interview.

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

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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