NCI OSFM Fitness Survey

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

TITLE OF INFORMATION COLLECTION: NCI OSFM Fitness Center Survey

PURPOSE:

The NCI Fitness Center is one of the many services offered by the Office of Space and Facilities Management at NCI Shady Grove. The Fitness Center has 500 active members, 448 federal staff members and 54 contracted employees that use the fitness facility. Operated by Federal Occupational Health (FOC) the NCI Fitness Center offers 21 group exercise classes per week including yoga, pilates, Zumba, kickboxing, boot camp and strength training. The Fitness Survey is sent out to Fitness Center members allowing OSFM and Fitness Center staff to receive customer feedback on the services and improve service delivery.

DESCRIPTION OF RESPONDENTS:

The NCI Fitness Center is sent to all NCI Fitness Center members including federal employees and contractors. We are seeking OMB Clearance for the non-federal employees that will be surveyed.

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: Gehmelle Johnson, Senior Program Analyst/COR

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 [ ] 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
Individual	536	1	2/60	18
Totals	536	536		18

Category of Respondent	Total Burden Hours	Wage Rate*	Total Burden Cost
Individual	18	$23.23	418.14
Totals	18		418.14

*Bureau of Labor Statistics Occupation Title “All Occupations” Code 00-0000 http://www.bls.gov/oes/current/oes_nat.htm#00-0000.

FEDERAL COST: The estimated annual cost to the Federal government is $2,088.66

Staff	Grade/Step	Salary	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Senior Program Analyst/COR	13/5	104,433	2		2088.66
Contractor Cost					0
Travel					0
Other Cost					0
Total					$2088.66

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?

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.

Attachment A- Survey

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