Request for Approval

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-0953)

TITLE OF INFORMATION COLLECTION:

Occupational Data for Health (ODH) Prototype usability testing

PURPOSE:

NIOSH has defined an Occupational Data for Health (ODH) information model that defines data to be collected within health information systems (e.g. Electronic Health Records) to improve patient care, patient outcomes and public health activities.

NIOSH is developing an ODH Prototype to define and test a methodology demonstrating how to collect self-reported ODH for health information systems. The prototype will be used to demonstrate and socialize the benefits and uses of collecting ODH in health information systems. It will provide a means to evaluate the complexity of adding this functionality to existing health information systems and to measure the time and user support required to collect ODH so the activity can be optimally incorporated into health care systems’ patient workflows. It could also be used by NIOSH investigators to capture the ODH of respondents participating in research studies and other areas of interest outside a healthcare setting.

Usability testing of the prototype will be conducted by asking individuals to interact with the software and enter sample ODH data elements as if he or she were completing a pre-visit questionnaire for an upcoming doctor’s appointment. Each individual will be asked to complete a pre-test and post-test survey to capture demographic information and their feedback on the prototype.

DESCRIPTION OF RESPONDENTS:

• Be actively working adults (18 years and older);

• Retired from a previous occupation (18 years and older), may still be working but not required;

• Proficient in English;

• Encompass a wide variety of occupations;

• Encompass a variety of education levels; and

• Reasonably be expected to be current or future patients that provide their clinician with information about themselves.

TYPE OF COLLECTION: (Check one)

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

[X ] 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: Margaret S. Filios

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

BURDEN HOURS

Type of Respondent	Form Name	Number of Respondents	Number of Responses per Respondent	Average Hours Per Response	Burden Hours
Individuals	Pre-test	100	1	7/60	12
	ODH Prototype	100	1	30/60	50
	Post-test	100	1	8/60	13

FEDERAL COST: The estimated annual cost to the Federal government is ______0______

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?

IT Contractor has this as a contract task. Contractor will be responsible for finding respondents willing to provide feedback on their experience using the ODH Prototype. Contractor and project team will be leveraging personal and professional relationships to recruit 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

[ X ] In-person

[ ] Mail

[ X ] Other, Explain

Interviews will primarily be in person, but Skype may also be used. Interviewers will record reactions to the ODH Prototype via paper and electronic documentation. Pre and Post Surveys will be used to document interactions and reactions to the prototype. ODH data entered will be stored in a SQL database. No PII will be captured.

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

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

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

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 or groups for this collection of information. These groups must have experience with the program.

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

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

Personally Identifiable Information: Provide answers to the questions.

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 and divide by 60.

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 all instruments, instructions, and scripts are submitted with the request.

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