Generic Clearance Submission Form - Blue Star 2012

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 3135-0128)
TITLE OF INFORMATION COLLECTION:
Blue Star Museums Participant Survey Summer 2011
PURPOSE:
The purpose of this information collection is to solicit opinions from individuals who
participated in the Blue Star Museums program during the summer of 2011. The information
collected from respondents will be used by the NEA to identify the number of program attendees
and to improve future implementation of this program.
DESCRIPTION OF RESPONDENTS:
The respondents are staff members of the museums who participated in the Blue Star Museums
program. Blue Star Museums is a program that offers free admission to museums for all active
duty military personnel and their families from Memorial Day, May 30, through Labor Day,
September 5, 2011. More than 1,500 museums in all 50 states and the District of Columbia,
Puerto Rico, and American Samoa are participating in Blue Star Museums program. These
include children's museums, fine art museums, history and science museums, and nature centers.
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:
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: Steven Shewfelt
To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [X] No

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2. If Yes, is the information that will be collected included in records that are subject to the
Privacy Act of 1974? [ ] Yes [X] No
3. If Applicable, has a System or Records Notice been published? [ ] Yes [X] 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
1,881
---

Individuals (survey)
Totals

Participation
Time
15
---

Burden
470.25
470.25

FEDERAL COST: The estimated annual cost to the Federal government is $625.
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 entire population of Blue Star Museum participants (n = 1,881) will be surveyed. The
surveys will be administered online, using SurveyMonkey.

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
Please make sure that all instruments, instructions, and scripts are submitted with the
request.

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Instructions for completing Request for Approval under the “Generic
Clearance for the Collection of Routine Customer Feedback”
TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the
subject of the request. (e.g. Comment card for soliciting feedback on xxxx)
PURPOSE: Provide a brief description of the purpose of this collection and how it will be used.
If this is part of a larger study or effort, please include this in your explanation.
DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or
groups for this collection of information. These groups must have experience with the program.
TYPE OF COLLECTION: Check one box. If you are requesting approval of other
instruments under the generic, you must complete a form for each instrument.
CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the
collection will be returned as improperly submitted or it will be disapproved.
Personally Identifiable Information: Provide answers to the questions.
Gifts or Payments: If you answer yes to the question, please describe the incentive and provide
a justification for the amount.
BURDEN HOURS:
Category of Respondents: Identify who you expect the respondents to be in terms of the
following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal
governments; or (4) Federal Government. Only one type of respondent can be selected.
No. of Respondents: Provide an estimate of the Number of respondents.
Participation Time: Provide an estimate of the amount of time required for a respondent to
participate (e.g. fill out a survey or participate in a focus group)
Burden: Provide the Annual burden hours: Multiply the Number of responses and the
participation time and divide by 60.
FEDERAL COST: Provide an estimate of the annual cost to the Federal government.
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. Please provide a description of how you plan to
identify your potential group of respondents and how you will select them. If the answer is yes,
to the first question, you may provide the sampling plan in an attachment.
Administration of the Instrument: Identify how the information will be collected. More than
one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or
facilitators (e.g., for focus groups) used.

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Please make sure that all instruments, instructions, and scripts are submitted with the
request.

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