IC Template for Tax Time Customer Survey

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)
1. TITLE OF INFORMATION COLLECTION:
2014 Tax Time Savings Campaign Evaluation Form
2. PURPOSE:
To gather information on the effectiveness of training that CFPB provides to selected VITA sites.

3. DESCRIPTION OF RESPONDENTS:
Site administrators and coordinators at approximately 15 VITA sites. The sites have entered into agreements with the
CFPB to participate in the Tax Time savings campaign.

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

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

5. FOCUS GROUP OR SURVEY:
If you plan to conduct a focus group or survey, please provide answers to the following
questions:
a. 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 [ ] Not Applicable
b. If the answer is yes, please provide a description below. 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?
We will ask all participants in the Tax Time training for VITA site administrators to respond to the survey questions.

6. PERSONALLY IDENTIFIABLE INFORMATION:
a. Is personally identifiable information (PII) collected? [ ] Yes [X] No
b. 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
c. If Applicable, has a System or Records Notice been published?
[ ] Yes [ ] No [X] Not Applicable
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7. GIFTS OR PAYMENTS:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation)
provided to participants? [ ] Yes [X] No
8. ADMINISTRATION OF THE INSTRUMENT:
a. 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 __Paper responses will be collected______
b. Will interviewers or facilitators be used?
[ ] Yes [X] No [ ] Not Applicable
9. BURDEN ESTIMATES:
Information Collection

Totals

Number of
Participation
Burden
Hours
Respondents
Time
Less than 100 5 minutes
8
Less than 100 /////////////////////// 8

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

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By submitting this document, the Bureau certifies the following to be true:
The collection is voluntary.
The collection is low-burden for respondents and low-cost for the Federal Government.
The collection is non-controversial and does not raise issues of concern to other federal
agencies.
The results are not intended to be disseminated to the public.
Information gathered will not be used for the purpose of substantially informing influential
policy decisions.
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.
The results will not be used to measure regulatory compliance or for program
evaluation

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