Justification Form for a Survey



U.S. Department of the Interior

Office of Policy Analysis



Justification for a Survey under the Department of the Interior’s Programmatic Clearance for Customer Satisfaction Surveys



Revised March 2012

Instructions for Completing Justification for DOI Programmatic Clearance Submission, OMB Control Number 1040-0001



1. Survey Title/Date Submitted to the Office of Policy Analysis (PPA): Insert title for the proposed survey. Insert date that the expedited approval package will be submitted to PPA. Reminder: Please submit the package through your bureau/office Information Collection Clearance Officer.

2. Bureau/Office: Insert the name of the bureau/office conducting the survey.

3. Abstract: Summarize the proposed study with an abstract not to exceed 150 words.

4. Bureau/Office Point of Contact Information: Complete the bureau/office contact information. PPA will communicate with the point of contact listed here throughout the entire approval process.

5. Principal Investigator (PI) Conducting the Survey: Complete information about the PI who will be conducting the survey, if different than Point of Contact listed in #4. Otherwise note: Same as #4.

6. Name of Program Office Conducting Survey: Provide the name of the bureau program, office, or organizational unit conducting the survey.

7. Description of Customers and Services Provided: Provide a brief description of the customers who will be surveyed, the services provided by the program conducting the survey, and how these services are provided to customers.

8. Survey Dates: List the time period in which the survey will be conducted, including specific starting and ending dates. The starting date should be at least 45 days after the submission date. The request for expedited approval, and submission of a complete and accurate approval package, must be made at least 45 calendar days prior to the first day the PI wishes to administer the survey instrument to the public.

9. Type of Information Collection Instrument: Check the type(s) of information collection instrument(s) that will be used. If other, please explain.

10. Survey Development: Explain how the survey was developed. With whom did you consult during the development of the survey on content? On statistics? Did you pretest the survey? What actions did you take to improve the survey? What suggestions did you receive for improving the survey? Which of the six topic areas will be addressed? (Note: A description of any pre-testing and peer review of the methods and/or instrument is highly recommended.)

11. Survey Methodology: Explain how the survey will be conducted. Provide a description of the survey methodology including: (a) How will the customers be sampled? (if fewer than all customers will be surveyed); (b) What percentage of customers asked to take the survey will respond, and (c) What actions are planned to increase the response rate? If statistics are generated, this description must be specific and include each of the following:

- The respondent universe,

- The sampling plan and all sampling procedures;

- How the instrument will be administered;

- Expected response rate and confidence levels; and

- Strategies for dealing with potential non-response bias.

Note: Web-based surveys are not an acceptable method of sampling a broad population. Web-based surveys must be limited to services provided by the web site.

12. Total Number of Initial Contacts and Expected Number of Respondents: Provide an estimated total number of initial contacts and the total number of expected respondents.

13. Estimated Time to Complete Initial Contact and Time to Complete Survey Instrument: Estimate the time to complete the initial contact and the time to complete the survey instrument (in minutes).

14. Total Burden Hours: Provide the total number of burden hours. The total burden hours should account for the amount of time required to instruct the respondents in completing the survey, and the amount of time required for the respondent to complete the survey.

15. Reporting Plan: Provide a brief description of the reporting plan for the data being collected.

16. Justification, Purpose and Use: Provide a brief justification for the survey, its purpose, goals, and utility to managers. Specifically, describe how data will be tabulated and what statistical techniques will be used to generalize the results to the entire customer population. Describe how data from the survey will be used. Describe how you will acknowledge any limitations related to the data, particularly in cases where we obtain a lower than anticipated response rate. Note whether or not the survey is intended to measure a Government Performance and Results Act (GPRA) performance measure.

Justification for Submission under DOI Programmatic Clearance for Customer Satisfaction Surveys (OMB Control Number 1040-0001)

U.S. Department of the Interior Office of Policy Analysis (PPA)

PPA Tracking Number: (for PPA use only)

			Date Submitted to PPA:
1.	Survey Title:
2.	Bureau:



3.	Abstract: (not to exceed 150 words)

4.

Bureau/Office Point of Contact Information

First Name:

Last Name:

Title:

Bureau/Office:

Street Address:

City:

State:

Zip code:

Phone:

Fax:

Email:

5.

Principal Investigator (PI) Information

First Name:

Last Name:

Title:

Bureau/Office:

Address:

City:

State:

Zip code:

Phone:

Fax:

Email:

6.

Name of Program or Office Conducting Survey:

7.

Description of Customers and Services Provided:

8.

Survey Dates

(mm/dd/yyyy)

to

(mm/dd/yyyy)

9.

Type of Information Collection Instrument (Check ALL that Apply)

__Intercept

__Telephone

__Mail

__Web-based

__Focus Groups

__Comment Cards

__Other

Explain:

10. Survey Development: (Who assisted in survey content development statistics? Was the survey pretested? How were improvements integrated? Which of the six topic areas will be addressed?)
11. Survey Methodology: (Use as much space as needed; if necessary include additional explanation on separate page).
Respondent Universe
Sampling Plan/Procedure
Instrument Administration
Expected Response Rate and Confidence Levels
Strategies for dealing with potential non-response bias
Description of any pre-testing and peer review of the methods and/or instrument (recommended)
12.	Total Number of Initial Contacts and Expected Number of Respondents
13.	Estimated Time to Complete Initial Contact and Time to Complete Instrument
14.	Total Burden Hours Contacts Respondents ----------------- Total
15. Reporting Plan:

16. Justification, Purpose, and Use:
Survey Justification and Purpose
Survey Goals
Utility to Managers
How will the results of the survey be analyzed and used?
How will the data be tabulated? What Statistical Techniques will be used to generalize the results to the entire customer population? How will limitations on use of data be handled? If the survey results in a lower than anticipated response rate, how will you address this when reporting the results? (Use as much space as needed; if necessary include additional explanation on separate page).
Is this survey intended to measure a Government Performance and Results Act (GPRA) performance measure? If so, please include an excerpt from the appropriate document. (Use as much space as needed; if necessary include additional explanation on separate page).

Checklist for Submitting a Request to Use DOI Programmatic Clearance for Customer Satisfaction Surveys

• All questions in the survey instrument are within the scope of one of the DOI Programmatic Clearance for Customer Satisfaction Surveys topic areas.



• The approval package is being submitted to the Office of Policy Analysis at least 45 days prior to the first day the PI wishes to administer the survey to the public.



• A qualified statistician has reviewed and approved your request.



• Your bureau/office Information Collection Clearance Officer has reviewed and approved the approval package.



The approval package includes:

• A completed Justification

•  A signed Certification Form

• A copy of the survey instrument

• Other supporting materials, such as:

• Cover letters to accompany mail-back questionnaires

• Introductory scripts for initial contact of respondents

• Necessary Paperwork Reduction Act compliance language

• Follow-up letters/reminders sent to respondents



The survey methodology presented in the Justification includes a specific description of:

• The respondent universe

• The sampling plan and all sampling procedures, including how respondents will be selected

• How the instrument will be administered

• Expected response rate and confidence levels

•  Strategies for dealing with potential non-response bias

• A description of any pre-testing and peer review of the methods and/or the instrument is highly recommended.



• The burden hours reported in the Justification include the number of burden hours associated with the initial contact of all individuals in the sample (i.e., including refusals), if applicable, and the number of burden hours associated with individuals expected to complete the survey instrument.

• The package is properly formatted (Word) and submitted to the Office of Policy Analysis electronically. 

CERTIFICATION FORM FOR SUBMISSION UNDER OMB CONTROL NUMBER 1040-0001

This form should only be used if you are submitting a collection of information for approval under the DOI Programmatic Clearance for Customer Satisfaction Surveys.

If the collection does not satisfy the requirements of the Programmatic Clearance, you should follow the regular PRA clearance procedures described in 5 CFR 1320.

Bureau/Office Subgroup or Program
Title (Please be specific)
Estimated Number Contacts Respondents			Time per Response Contacts Respondents
			Total Burden Hours Contacts Respondents ----------------- Total
Bureau/Office Contact (who can best answer questions about content of the submission):
Name				Phone
Certification: The collection of information requested by this submission meets the requirements of OMB control number 1040-0001
Bureau/Office Qualified Statistician						DATE
Bureau/Office Information Collection Clearance Officer						DATE
Office of Policy Analysis						DATE
OMB, Office of Information and Regulatory Affairs (OIRA)						DATE

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