Empowerment Convening Evaluation Questions

Request for Approval under the “Generic Clearance for the Collection of
Qualitative Feedback on the Service Delivery of the Consumer Financial
Protection Bureau” (OMB Control Number: 3170-XXXX)
TITLE OF INFORMATION COLLECTION:
Empowerment Convening Evaluation Questions
PURPOSE:
The purpose of this form is to solicit feedback from individuals who were invited to participate
in a convening hosted by the Office of Financial Empowerment at the Consumer Financial
Protection Bureau on November 28-29. This feedback will help the Office assess the
effectiveness and usefulness of the convening, its strengths and weaknesses, and help understand
better the perspective of the participants with regard to the topics presented at the convening.
DESCRIPTION OF RESPONDENTS:
Approximately 150 individuals who were invited to participate in a convening hosted by the
Office of Financial Empowerment at the Consumer Financial Protection Bureau on November
28-29.
TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[X] Customer Satisfaction Survey
[ ] Small Discussion Group
[ ] Other: ______________________

CERTIFICATION:
By submitting this document, the Bureau certifies 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.

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Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [X] 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
150
150

Survey Respondents
Totals

Participation
Time
10 minutes
N/A

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

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Burden
25 hours
25 hours

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?
The purpose of this form is to solicit feedback from individuals who were invited to participate
in a convening hosted by the Office of Financial Empowerment at the Consumer Financial
Protection Bureau on November 28-29. This feedback will help the Office assess the
effectiveness and usefulness of the convening, its strengths and weaknesses, and help understand
better the perspective of the participants with regard to the topics presented at the convening.
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
[X] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ ] Yes [X] No
Please make sure that all instruments, instructions, and scripts are submitted with the
request.

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