Program Evaluation Instruments - Collaborative Problem Solving Mediation Services (Two Instruments)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 3320 0004(1) Mediation Services Participant Questionnaire Rev 2012	Form and Instruction	Modified	Available
Form 3320-0004(2) Mediation Services - Practitioner Questionnaire (Rev 2011)	Form and Instruction	Modified	Available
Form 3320-0004(2) Mediation Services - Practitioner Questionnaire (Rev 2011)	Form and Instruction	Modified	Available
Form 3320 0004(1) Mediation Services Participant Questionnaire Rev 2012	Form and Instruction	Modified	Available
Form 3320 0004(1) Mediation Services Participant Questionnaire Rev 2012	Form and Instruction	Modified	Repair queued
Form 3320 0004(1) Mediation Services Participant Questionnaire Rev 2012	Form and Instruction	Modified	Available
Supporting Statement A and B_Mediation Services 33200004_02 03 2012.pdf	Supplementary Document	Uploaded 2012-06-13	Available
Supporting Statement A and B_Mediation Services 33200004_11 14 11.pdf	Supporting Statement B	Uploaded 2011-11-15	Available
Supporting_Statement_A_and_B_Mediation_Services_33200004_02_03_2012.pdf	Supporting Statement A	Uploaded 2012-06-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
35885	Evaluation of Mediation Services (Participant) - IC for Federal Respondents	Form and Instruction	Modified	Mediation Services Participant Questionnaire Rev 2012
185875	Evaluation of Mediation Services (Practitioner) - IC for Private Sector Respondents	Form and Instruction	Modified	Mediation Services - Practitioner Questionnaire (Rev 2011)
185874	Evaluation of Mediation Services (Practitioner) - IC for Federal Respondents	Form and Instruction	Modified	Mediation Services - Practitioner Questionnaire (Rev 2011)
185873	Evaluation of Mediation Services (Participant) - IC for Individual or Household Respondents	Form and Instruction	Modified	Mediation Services Participant Questionnaire Rev 2012
185872	Evaluation of Mediation Services (Participant) - IC for Private Sector Respondents	Form and Instruction	Modified	Mediation Services Participant Questionnaire Rev 2012
185871	Evaluation of Mediation Services (Participant) - IC for State, Local and Tribal Govt. Respondents	Form and Instruction	Modified	Mediation Services Participant Questionnaire Rev 2012

ICR Details

OMB Control No: 3320-0004	ICR Reference No: 201012-3320-001
Status: Historical Active	Previous ICR Reference No: 200807-3320-013
Agency/Subagency: MKU-SLUF	Agency Tracking No: 0004
Title: Program Evaluation Instruments - Collaborative Problem Solving Mediation Services (Two Instruments)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/13/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/15/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	36 Months From Approved	06/30/2012
Responses	1,975	0	2,250
Time Burden (Hours)	595	0	761
Cost Burden (Dollars)	0	0	0

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Abstract: As part of its program evaluation system, the U.S. Institute for Environmental Conflict Resolution plans to collect information on the quality of its services from contractors and users of its services.

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Authorizing Statute(s): PL: Pub.L. 105 - 156 5 Name of Law: Environmental Pollicy and Conflict Resolution Act of 1998
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 44611	07/26/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 63661	10/13/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Evaluation of Mediation Services (Participant) - IC for Federal Respondents	3320 0004(1)	Mediation Services Participant Questionnaire Rev 2012
Evaluation of Mediation Services (Participant) - IC for Individual or Household Respondents	3320 0004(1)	Mediation Services Participant Questionnaire Rev 2012
Evaluation of Mediation Services (Participant) - IC for Private Sector Respondents	3320 0004(1)	Mediation Services Participant Questionnaire Rev 2012
Evaluation of Mediation Services (Participant) - IC for State, Local and Tribal Govt. Respondents	3320 0004(1)	Mediation Services Participant Questionnaire Rev 2012
Evaluation of Mediation Services (Practitioner) - IC for Federal Respondents	3320-0004(2)	Mediation Services - Practitioner Questionnaire (Rev 2011)
Evaluation of Mediation Services (Practitioner) - IC for Private Sector Respondents	3320-0004(2)	Mediation Services - Practitioner Questionnaire (Rev 2011)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,975	2,250	0	-275	0	0
Annual Time Burden (Hours)	595	761	0	-166	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The evaluation instrument has been streamlined from the earlier versions approved under OMB control number 3320-0004 (expiring 12/31/2011). Note: The above summary of annual time burden in hours differs slightly from the attached supporting statement due to rounding.

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Annual Cost to Federal Government: $22,846

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/15/2011

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