Fast Track Submission Form -Not for profit

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0648 ExpDate: 3/31/18)

T ITLE OF INFORMATION COLLECTION: The Annual NIH Pain Consortium Symposium Feedback

PURPOSE:

The NIH Pain Consortium sponsors an annual symposium on a significant topic relevant to pain. This symposium features NIH supported researchers whose work has made an important contribution to pain research. In addition to speakers and panel sessions, there is a poster session featuring early career investigators. Researchers with the best abstracts are selected to give an oral presentation, and the best presenter receives the Mitchell Max Award for Best Poster.

DESCRIPTION OF RESPONDENTS: The survey will be open to all symposium attendees. The attendees are a combination of federal and non-federal people including clinicians, researchers, patients, patient advocates, students and NIH staff.

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: Nadia Douaji

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 [x] NA

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

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [ x ] No

ESTIMATED BURDEN HOURS and COSTS

Category of Respondent	No. of Respondents	No. of Responses per Respondent	Time per Response (in hours)	Total Burden Hours
Private Sector (not-for-profit)	20	1	4/60	1
Totals	20			1

Category of Respondent	Total Burden Hours	Wage Rate*	Total Burden Cost
Private Sector (not-for profit)	1	$75/hour	$75
Totals	1		$75

*Cite source per bls.gov if applicable

Bls.gov Occupational Employment and Wages, http://www.bls.gov/oes/current/oes_dc.htm

FEDERAL COST: The estimated annual cost to the Federal government is _____$306_______

Staff	Grade/Step	Salary	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
PM	13/5	103,000	0.1		$103
Web M	13/5	103,000	0.1		$103
Contractor Cost
Web Developer	NA	100,000	0.1		$100
Travel
Other Cost

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 the list of the conference attendees.

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

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

We will be using surveymonkey. Please find attached with this request, the screenshot of the survey.

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