Survivorship Transplant sub-study

Request for Approval under the “Generic Clearance for NIH Citizen Science and Crowdsourcing Projects”

(OMB#: 0925-0766 Exp., date: 04/2023)

TITLE OF INFORMATION COLLECTION: Survivorship Survey for Post-Transplant Interdisciplinary Providers (NCI)

PURPOSE:

The purpose of the survey is to gather information and resources needed about survivorship topics across interdisciplinary teams. The survey will be used to develop patient and provider education and resources. Primarily, these conversations occur during Day 100+ post-transplant follow-up visits. Given the specific needs of the patient and the healthcare specialty, the clinician may touch on some of these topics during the pre-transplant, transplant hospitalization, or initial 100 days post-transplant.

The survey is organized by body system, organs and psychosocial concerns with three questions associated with each: if the topic is addressed in the visit, comfort level addressing the topic, and the need for additional education or resources for the patient. Clinicians will also be asked if they are interested in developing patient education and resources regarding post-transplant survivorship topics.

DESCRIPTION OF RESPONDENTS:

The target group is all members of the Clinical Center inter-institute transplant consortium. It is an interdisciplinary group of healthcare professionals working with patients who are or have received a transplant at NIH. There are 159 individuals on the consortium email distribution list.

TYPE OF COLLECTION: (Check one)

[ ] Data Catalogue [ ] Repository of Tools and Best Practices

[ ] Recommendations of scientific reviewers [X] Resources

[ ] Call for Nominations [ ] 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. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

5. 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:____ Jennifer Hendricks ____________________________________________

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
Individuals	159	1	15/60	40
Totals		159		40

Category of Respondent	Total Burden Hours	Hourly Wage Rate*	Total Burden Cost
Individuals	40	$46.95	$1878.00
Total

*The Mean Hourly Wage rate for Medical Scientists, https://www.bls.gov/oes/2019/May/oes_nat.htm#00-0000

FEDERAL COST: The estimated annual cost to the Federal government is ____$2187____

Staff	Grade/Step	Salary*	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight	GS 12 / 9	$109,362	2%		$2187.24
Contractor Cost
Travel
Other Cost
Total					$2187.24

*the Salary in table above is cited from https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/2020/general-schedule/

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?

All individuals who are part of the transplant consortium email distribution list will receive a copy of the survey. This is a voluntary survey and some may choose not to participate.

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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