Fast-Track Template

Request for Sub-Study Approval under the NIMH Fast Track Generic Clearance:

“NIMH Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

(OMB Control Number: 0925-0650; Expiration Date: 1/31/2015)

T ITLE OF INFORMATION COLLECTION:

PURPOSE:

DESCRIPTION OF RESPONDENTS:

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 [ ] 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: ________________________________________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [ ] No

2. If yes, is the information collected in records subject to the Privacy Act of 1974?

[ ] Yes [ ] No

3. If applicable, has a System of Records Notice been published? [ ] Yes [ ] No

Gifts or Payments:

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

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time (in hours)	Burden
Totals

FEDERAL COST: The estimated annual cost to the Federal government is: ____________

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

[ ] Yes [ ] No

If yes, please provide a description (or attach the sampling plan).

If no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

2. Do you have a sampling plan for selecting from this universe?

[ ] Yes [ ] No

If yes, please provide a description and attach the sampling plan.

If no, please provide a description of how you plan to identify and select your target respondents.

Administration of the Instrument:

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [ ] No

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

Instructions for completing Request for Approval under the

“NIMH Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

TITLE OF INFORMATION COLLECTION: Provide the name of the information collection that is the subject of the request. (e.g., comment card for soliciting feedback)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group(s) for this collection of information. .

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic clearance, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify the information collection statements, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Please indicate if any sensitive or personally identifiable information (PII) will be collected. PII is defined as any information about an individual maintained by an agency, including, but not limited to, education, financial transactions, medical history, and criminal or employment history and information which can be used to distinguish or trace an individual's identity, such as their name, social security number, date and place of birth, mother’s maiden name, biometric records, etc., including any other personal information which is linked or linkable to an individual.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households; (2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time to get the total burden hours..

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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: Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

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

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