Generic IC Request Template

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: 3170-0024)
TITLE OF INFORMATION COLLECTION:
Financial Educator Forum End-of-Session Survey
PURPOSE:
Evaluation to measure participant response to the training.
DESCRIPTION OF RESPONDENTS:
Approximately 200 field practitioners from the Department of Defense to include staff financial educators, Judge
Advocate General officers and staff, and staff relocation specialists. The respondents will be a mix of GS employees,
active duty and reserve military, and contract staff. This request is being made to obtain approval to collect this
information from non-military and non-Federal respondents.

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.
7. The results will not be used to measure regulatory compliance or for program
evaluation.
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 [X ] Not Applicable
3. If Applicable, has a System or Records Notice been published?
[ ] Yes [ ] No [X ] Not Applicable
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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

Number of
Participation
Respondents
Time
200
.05

Federal Government

Burden
Hours

Totals
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?
The customer list will be the Forum Attendees.
Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[x] Web-based or other forms of Social Media (email fillable form to participants)
[ ] Telephone
[ ] In-person
[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ ] Yes [x] No

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