Fast Track Submission Form -Not for profit

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0648 Expiration Date: 03/2018)

T ITLE OF INFORMATION COLLECTION:

Medicine: Mind the Gap NIH Seminar Series Survey

PURPOSE:

The purpose of the survey is to determine if the seminar series meets the participant’s needs and to assess their level of satisfaction. Information collected in the survey will also be used to develop and enhance future lectures based on the participants’ interests.

DESCRIPTION OF RESPONDENTS:

Respondents will comprise individuals who participate in the Mind the Gap Seminar via webinar. They will represent the NIH community, academic institutions, and other governmental and non-governmental agencies.

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: Ranell Myles

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 [ X ] 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

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)	150	1	5/60	13
Totals	150	150		13

Category of Respondent	Total Burden Hours	Hourly Wage Rate*	Total Burden Cost
Private Sector	13	$39.03	507.39
Totals	13		507.39

*Cite source per bls.gov if applicable

19-0000; Life, Physical, and Social Science Occupations; http://www.bls.gov/oes/current/naics4_541700.htm

FEDERAL COST: The estimated annual cost to the Federal government is $763.78.

Staff	Grade/Step	Salary	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Public Health Analyst	GS-12 Step 1	76,378	1.0		$763.78
Contractor Cost			0		0
Travel
Other Cost
Total					$763.78

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?

Participants who registered for the webinar and provided their email address will be eligible to participate in the survey. At the end of the seminar, participants will receive a follow-up email with a link to complete the survey and asked to provide feedback. The survey will be administered via Survey Monkey.

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.

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