APEF PreSurvey Clearance Form

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: XXXX-YYYY)

TITLE OF INFORMATION COLLECTION: Asia-Pacific Economic Forum (APEF) Opening Symposium Pre-Survey

PURPOSE: The survey will collect feedback on the backgrounds and interests of participants attending the event, as well as feedback on which panel discussion they would like to attend.

DESCRIPTION OF RESPONDENTS: The respondents will be participants and attendees of the APEF Opening Symposium

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 [x ] Other: Background information

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: Tuyet Doung

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [X] 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 [X] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals or Households	175	10 minutes	29 hours
Totals	175	10 minutes	29 hours

FEDERAL COST: The estimated annual cost to the Federal government is $0.

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?

Our potential group of respondents will be those who RSVP to the Opening Symposium event. We are distributing the survey as a follow-up email/confirmation to their RSVP.

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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