National Institute of Mental Health (NIMH) Professional Coalition for Research Progress Meeting Assessment Form

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0648 Expiration Date: 03/2018)

TITLE OF INFORMATION COLLECTION:

National Institute of Mental Health (NIMH) Professional Coalition for Research Progress Meeting Assessment Form

PURPOSE:

To collect feedback from attendees of the NIMH Professional Coalition for Research Progress meeting to assess their satisfaction with the event and solicit ideas for improving subsequent meetings. NIMH convenes this meeting to share the latest research advances and related developments at NIMH, foster dialogue on the future path and directions of NIMH-funded research, and to encourage facilitated dialogue, networking, and interactions among stakeholders and NIMH leadership.

DESCRIPTION OF RESPONDENTS:

Respondents are senior leaders and representatives from national professional organizations with an interest in mental health research who are members of the NIMH Professional Coalition for Research Progress.

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: ^{Dr. Julie Mason, Deputy Director, OSPPC/NIMH}

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? Yes 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 _✔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
Private Sector	65	1	2/60	2
Totals	65	1		2

Category of Respondent	Total Burden Hours	Hourly Wage Rate*	Total Burden Cost
Private Sector	2	$50.47/hour	$100.94
Totals			$100.94

_{*Cite source per bls.gov if applicable} https://www.bls.gov/oes/2016/may/oes119199.htm

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

$1,319.00

Staff	Grade/Step	Salary	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Program Analyst	13/4	$106,668	0.6%		$640
Program Analyst	13/6	$113,132	0.6%		$679
Contractor Cost
Travel
Other Cost
Total					$1319.00

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 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?

Respondents are members of the NIMH Professional Coalition for Research Progress with an interest in mental health research.

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} Paper form distributed at the meeting

2. Will interviewers or facilitators be used? Yes

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

2

Last updated: August 2016