PBGC Generic Clearance Template

DOCUMENTATION FOR THE GENERIC CLEARANCE

OF CUSTOMER SERVICE SATISFACTION COLLECTIONS

TITLE OF INFORMATION COLLECTION:

(the collection that is the subject of the 10-day review request)

[ ] SURVEY [ ] FOCUS GROUP [ ] SOFTWARE USABILITY TESTING

DESCRIPTION OF THIS SPECIFIC COLLECTION

Specify all relevant information, including

1. intended purpose,

2. need for the collection,

3. planned use of the data,

4. date(s) and location(s),

5. collection procedures,

6. number of focus groups, surveys, usability testing sessions

7. description of respondents/participants,

Attach a copy of the proposed collection instrument, e.g., survey questions, focus group script, usability testing plan. If a focus group also includes a survey, include both.

AMOUNT OF ANY PROPOSED STIPEND OR INCENTIVE

In general, the payment should not exceed $25. PBGC will consult with OMB if it believes that a payment exceeding $25 is justified based on factors such as high parking fees at a focus group location, potential for inclement weather or other conditions exacerbating travel difficulties, length or complexity of the subject matter, participant recruitment difficulties, or consequences of attendance failures.

BURDEN HOUR COMPUTATION (Number of responses (X) estimated response or participation time in minutes (/60) = annual burden hours):

Category of Respondent	No. of Respondents	Participation Time	Burden
Totals

BURDEN COST COMPUTATION

Category of Respondent	No. of Respondents	Hourly Rate	Response Time	Total
Totals

STATISTICAL INFORMATION

If statistical methods are to be used, fully describe the methodology, sample selection, expected response rates, and any other concepts needed to provide a full understanding of those methods.

NAME OF CONTACT PERSON:

TELEPHONE NUMBER:

MAILING LOCATION:

PBGC DEPARTMENT, OFFICE, DIVISION, BRANCH:

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