Fast Track Submission Form

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0925-0655) ExpDate:04/30/2018

T ITLE OF INFORMATION COLLECTION:

User Survey for In-Home Drug Deactivation System

PURPOSE:

The user surveys are directed towards a) those who distribute the drug deactivation product (physicians, police forces etc), b) and those who are provided the product for use (end users).

The questionnaire for providers is intended to assess the frequency and circumstances in which they are furnishing the product, the benefits they see to use of the product, and any recommendations for improving it.

For end user assessments, a website survey mechanism will gather information related to degree of adherence, ease of use, reasons for using the product, a proactive solicitation for adverse events related to use of the product, a question relating to the benefits they see from use of the product, and recommendations for improving the product.

To investigate the potential longer-term impact on poisoning statistics, the questionnaires will ask reasons for utilizing the product, to determine the proportion of users motivated by poisoning risk (e.g. parents of small children), and to investigate other motivations for use, such as abuse risk, environmental contamination risk etc.

DESCRIPTION OF RESPONDENTS:

The respondents will be end-users of prescription pharmaceuticals. Providers will be physicians, pharmacists, health care workers, drug abuse counseling centers and the like.

TYPE OF COLLECTION: (Check one)

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

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

[ ] Focus Group [ X] Other: User and Provider Survey ______________________

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 and IC: Nathan Appel Ph.D., National Institute on Drug Abuse

________________________________________________

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? [X ] Yes [ ] No

A downloadable coupon for reward such as a coffee certificate or similar will be offered to respondents taking the online survey. There will be no additional incentive given to participants who elect to use the provided mail-in survey card rather than the online format.

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 (for profit) - Physicians	50	1	3/60	3
Totals	50			3

Category of Respondent	Total Burden Hours	Wage Rate*	Total Burden Cost
Business (for profit) - Physicians	3	93.00	$233.00
Totals			$233.00

*BLS for all occupations: http://www.bls.gov/oes/current/oes_nat.htm#00-0000

Physician’s rate used is 93.00/hr.

FEDERAL COST: The estimated annual cost to the Federal government is: The Phase 2 SBIR contract total is $969,648.00 over the two-year period. The one time cost of the survey is $4000 for supplies and download coupons

Staff	Grade/Step	Salary	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight	14-10	$139,523.00	1.1		$1534.75
Contractor Cost					$2000.00
Cost of the Survey					$4000.00
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? [ ] 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?

Providers (Physicians and Police), will receive product, and will be asked to distribute the product to householders. Providers will be surveyed as to their reasons for providing the product. Householders receive the product at no charge, accompanied by a survey card for mail-in or online response.

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

[ X ] Mail (A mail-back card provided with product at no cost)

[ ] 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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