Space Day Supporting Stmt Short Form

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 2700-0153)
TITLE OF INFORMATION COLLECTION: NASA Johnson Space Center Office of
Education Space Day Registration Form
PURPOSE: National Aeronautics and Space Administration (NASA) Johnson Space Center
Office of Education (OE) seeks clearance for a focus group to test a web-based form to collect
registration information from interested educational organizations to participate in Space Day
2013 activities. Educational hands-on activities for the students of the educational organizations
will be provided on the Texas State Capitol lawn. A focus group will:
- enable the collection of information from the public to engage students in science,
technology, engineering and mathematic (STEM) hands-on activities (allowing planners
to have sufficient supplies for all attendees)
- validate the estimated time to complete the registration form
- validate the Information Collection Instruments are sufficiently clear and comprehensible
DESCRIPTION OF RESPONDENTS: Texas educational organizations such as schools and
museums

TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ X] Focus Group

[] Customer Satisfaction Survey
[ ] Small Discussion 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:_________Linda Smith ______________________________________
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, will any information that is collected be included in records that are subject to the
Privacy Act of 1974? [ ] Yes [X] No
3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [X ]
No

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Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to
participants? [ ] Yes [X] No
BURDEN HOURS
Category of Respondent

No. of
Participation
Respondents Time

Individuals or Households
Private Sector
State, local or tribal governments
Federal Government
Total

Burden

70
70

10
10

12
12

140

10

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FEDERAL COST: The estimated annual cost to the Federal government is $1,360
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?
[X] 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?
JSC Office of Education maintains a contact list. Additionally, there are the uses of
NASA Education Express and NASA Educator Online Network which are dissemination
tools for anyone interested in NASA education activities.
The opportunity to register and participate will be emailed to these contacts as well as to
those who subscribe to NASA Education Express and NASA Educator Online Network.

Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[X] Web-based or other forms of Social Media
[ ] Telephone
[ ] In-person
[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ ] Yes [X] No

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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. Note: Agencies
should only collect PII to the extent necessary, and they should only retain PII for the period of
time that is necessary to achieve a specific objective.
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 per row.
No. of Respondents: Provide an estimate of the Number of Respondents.
Participation Time: Provide an estimate of the amount of time (in minutes) 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 Respondents and the
Participation Time then 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.

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

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