Generic Request Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0925-0648 exp. 1/2015)

T ITLE OF INFORMATION COLLECTION: Qualitative Research to Explore Young People’s Choices to Pursue a Career as a Physician Scientist

PURPOSE:

The purpose of the proposed research is to explore the attitudes of young medical, dental, and veterinary students toward careers as physician scientists, as well as the experiences of women physician-scientists. The findings will be used to inform the deliberations of the Physician Scientist Workforce Committee that will make recommendations to the NIH Director regarding actions that NIH should take to support a sustainable and diverse physician-scientist workforce.

DESCRIPTION OF RESPONDENTS:

The overall study will consist of two sub-studies. Respondents will consist of:

1. 15 research deans at medical, dental, and/or veterinary schools

2. 30 female physician-scientists who successfully obtained R01 grants, but did not submit a renewal application

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Groups [x ] Other: key informant interviews

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:____ _Sherry Mills MD.__________________________________________

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, 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 [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 Hours
Private (Research Deans)	15	30/60	8
Individuals (Women Physician-Scientists)	30	30/60	15
Totals	45		23

FEDERAL COST: The estimated annual cost to the Federal government $31,519.11

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?

For research deans, participants will be recruited from nominations by members of the Physician Scientist Workforce Committee.

For women physician scientists, participants will be recruited from among those who have successfully obtained an R01 award between 2001and 2008, but failed to submit a renewal application. We will randomly select from that pool of applicants.

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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