Fast Track Template

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

TITLE OF INFORMATION COLLECTION: Community Health Maps Project User Survey

PURPOSE: The Community Health Maps Project helps community organizations identify and apply low-cost and easy-to-use online mapping tools (GIS). The site is a collaborative effort between the National Library of Medicine, the Center for Public Service Communications, and Bird’s Eye View.

The goal of the survey is to assess community health organizations’ satisfaction with GIS / mapping resources currently available to them. The information will be used to improve the site and tailor it to specific user requirements.

DESCRIPTION OF RESPONDENTS: Respondents are staff of community and public health organizations interested in using free and low cost GIS / online mapping tools.

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: Alla Keselman

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 NA

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No NA

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
Private Sector (not- for -profit)	100	10/60	17 hours
Totals			17 hours

FEDERAL COST: The estimated annual cost to the Federal government is: $900_______

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?

The survey will be placed on the home page and major topic subsequent pages of Community Health Maps. Anyone who visits the site will be given the opportunity to complete the survey. In addition, the survey link will also be posted via a number of NLM / SIS listserves and social media handles. We will also promote the link via National Network of Libraries of Medicine. We want a broad section of potential responders.

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

Attachment: NLM CHMP Survey Instrument (SurveyMonkey screen shots)

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