Mini-Supporting Statement A template

Mini-Supporting Statement Template

NLM Generic Clearance to Conduct Voluntary Customer/Partner Surveys

OMB Control No: 0925-0476

Title of Study

Federal Government Employee Information:

Name:

Address:

Telephone:

Fax:

Email:

A. Justification

Abstract: This includes narrative information explaining the purpose, scope, and benefit(s) of the collection. Word length limited to 250 words, only.

A.1 Circumstances Making the Collection of Information Necessary

Explain the circumstances that make the collection of information necessary.

Identify any legal or administrative requirements that necessitate the collection. OMB requires that the Information Collection Request cite the specific legislative authority to conduct the information collection or research. Each IC has as part of its legislative authority a section that authorizes conducting research. There are links in the attached “points to consider” section to assist in identifying your legislative authority for your Institute or Center.

A.2 Purpose and Use of the Information Collection

Indicate how, by whom, and for what purpose the information is to be used. Indicate term of clearance (i.e., how long).

Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

Justify the data collection in terms of positive needs and the negative consequences of not having the information. Emphasize the practical utility to the government of the expected results. State the uses in specific and tangible terms. Avoid broad, general statements about research, or descriptive analyses. There should be some specific planned use, by a federal program, for the resulting data. This material is important, because projects may be disapproved because they lack “practical utility.” OMB normally will not consider data collections for programs which are not recommended for funding in the Administration budget for the coming year. Therefore, where appropriate, provide information on the program's budget status

A.3 Use of Information Technology and Burden Reduction

Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection.

Describe any consideration of using information technology to reduce the burden. Please identify if a Privacy Impact Assessment (PIA) was done for the database being used to collect the information.

A.4 Efforts to Identify Duplication and Use of Similar Information

Describe efforts to identify duplication. (i.e., duplication of the information requested in a new rule or form), and describe how the agency identified efforts to avoid duplication.

Show specifically why any similar information already available cannot be used or modified for use for the purposes described in A.2.above.

A.5 Impact on Small Businesses or Other Small Entities

If the collection of information impacts small businesses or other small entities, describe any methods used to minimize the burden.

A.6 Consequences of Collecting the Information Less Frequently

Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

A.7 Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

Explain any special circumstances that would cause an information collection to be conducted in a manner:

1. requiring respondents to report information to the agency more often than quarterly;

2. requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

3. requiring respondents to submit more than an original and two copies of any document;

4. requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than 3-years;

5. in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

6. requiring the use of statistical data classification that has not been reviewed and approved by OMB;

7. that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

8. requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information’s confidentiality to the extent permitted by law.

A.8.1 Comments in Response to the Federal Register Notice

Provide date, volume and page number of published federal register notice. Provide public comments received in response to that notice and describe actions taken by the agency in response to these comments as an attachment. If no comments received, please state. Specifically address all comments received on cost and hour burden.

A.8.2 Efforts to Consult Outside Agency

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years--even if the collection of information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained. If more than five (5) were consulted please provide as an additional attachment

A.9 Explanation of Any Payment of Gift to Respondents

Explain any decision to provide any payment or gift to respondents, except remuneration of contractors or grantees. Reference incentives based on recent studies (less than 4 years old). Provide examples of other Federal Government studies that use similar incentives.

A.10 Assurance of Confidentiality Provided to Respondents

Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy. Provide a certificate of confidentiality (COA), if not applicable state “private to the extent permitted by law.”

Additionally please include whether Personally Identifiable Information (PII) is collected.

A.11 Justification for Sensitive Questions

Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, race, gender, etc., and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

A.12.1 Estimates of Hour Burden Including Annualized Hourly Costs

Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

Table 12-1 Estimated Annualized Burden Hours

Form Name	Type of Respondents	Number of Respondents	Number of Responses per Respondent	Average Burden Per Response (in hours)	Total Annual Burden Hours
A	General Public	500	1	1	500
B	Health Professionals	3,000	2	90/60	9,000
C	Health Educators	1,000	4	30/60	2,000
Total		4,500	10,500		11,500

A.12-2 Annual Cost to respondent

Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here.

Table 12-2 Annualized Cost to Respondents

Type of Respondents	Total Annual Burden Hours	Hourly Respondent Wage Rate*	Respondent Cost
General Public	500	$22.33	$11,165.00
Health Professionals	9,000	$35.93	$323,370.00
Health Educators	2,000	$27.94	$55,880.00
TOTAL	11,500		$390,415.00

*Bureau of Labor Statistics: The General Public rate was obtained from the http://www.bls.gov/oes/2013/may/oes_nat.htm#00-0000

The Health Professionals wage rate was obtained from http://www.bls.gov/oes/2013/may/oes290000.htm

Occupation title “Healthcare Practitioners and Technical Occupations”, occupation code 29-0000;

A.13 Estimate of Other Total Annual Cost Burden to Respondents or Record Keepers

Provide an estimate of the total annual cost burden to respondents or record-keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14)

The cost estimate should be split into two components: (a) a total capital and start-up cost component (annualized over its expected useful life); and (b) a total operation and maintenance and purchase of services component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information. Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

A.14 Annualized Cost to the Federal Government

Provide estimates of annualized cost to the Federal government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information.

Cost Descriptions	Grade/Step	Salary	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Contractor Cost
Travel
Other Cost
Total

*the Salary in table above is cited from https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/18Tables/html/DCB.aspx

At a minimum there should be federal oversight costs. Fill others as applicable. Shaded areas are exempt.

A.15 Explanation for Program Changes or Adjustments

N/A

A.16 Plans for Tabulation and Publication and Project Time Schedule

For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

A.16 - 1 Project Time Schedule
Activity	Time Schedule
Letters sent to respondents	1 - 2 months after OMB approval
Field questionnaire	3 - 8 months after OMB approval
Completed field work	8 - 9 months after OMB approval
Validation	10 - 12 months after OMB approval
Analyses	12 - 18 months after OMB approval
Publication	18 months after OMB approval

A.17 Reason(s) Display of OMB Expiration Date is Inappropriate

If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate. The OMB control number will be displayed (expiration date).

A.18 Exceptions to Certification for Paperwork Reduction Act Submissions

This survey will comply with the requirements in 5 CFR 1320.9. *standard text*

Mini Supporting Statement B

Complete SSB if, the collection of information employs statistical methods and make a separate document.

If the collection of information does not involve any statistical methods, please use the following statement: “This information does not involve statistical methods.”

B.1 Respondent Universe and Sampling Methods

Describe (including a numerical estimate) the potential respondent universe and any sampling or other respondent selection method to be used. Data on the number of entities (e.g., establishments, State and local government units, households, or persons) in the universe covered by the collection and in the corresponding sample are to be provided in tabular form for the universe as a whole and for each of the strata in the proposed sample. Indicate expected response rates for the collection as a whole. If the collection had been conducted previously, include the actual response rate achieved during the last collection.

B.2 Procedures for the Collection of Information

Describe the procedures for the collection of information including:

• Statistical methodology for stratification and sample selection;

• Estimation procedure;

• Degree of accuracy needed for the purpose described in the justification;

• Unusual problems requiring specialized sampling procedures; and

• Any use of periodic (less frequent than annual) data collection cycles to reduce burden.

B.3 Methods to Maximize Response Rates and Deal with Nonresponse

Describe methods to maximize response rates and to deal with issues of non-response. The accuracy and reliability of information collected must be shown to be adequate for intended uses. For collections based on sampling, a special justification must be provided for any collection that will not yield “reliable” data that can be generalized to the universe studied.

B.4 Test of Procedures or Methods to be Undertaken

Describe any tests of procedures or methods to be undertaken. Testing is encouraged as an effective means of refining collections of information to minimize burden and improve utility. Tests must be approved if they call for answers to identical questions from 10 or more respondents. A proposed test or set of tests may be submitted for approval separately or in combination with the main collection of information.

B.5 Individuals Consulted on Statistical Aspects and Individuals Collecting and/or Analyzing Data

Provide the name and telephone number of individuals consulted on statistical aspects of the design and the name of the agency unit, contractor(s), grantee(s), or other person(s) who will actually collect and/or analyze the information for the agency.

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