AttC Wrksht2 ATSDR Customer Satisfaction Survey

PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part 2: Information Collection Details

This template is intended for staff without an ICRAS account. Please fill out and submit to the appropriate Operating Division or Office to enter into ICRAS. The form mirrors the screens available in the ICRAS 4 system. Instructions for filling out the form are available at www.paperworkreduction.gov. To have an account setup to log into ICRAS, send an email request to [email protected].

Title

AttB. ATSDR Customer Satisfaction Survey Questionnaire

Is this a Common Form?

Yes

No

N/A

Obligation to respond (check one)

1. Voluntary

2. Required to obtain or retain benefits

3. Mandatory

Frequency of reporting (check all that apply)

1. Hourly (40 per week)

2. Daily

3. Weekly

4. Weekly (52 per year)

5. Monthly

6. Yearly

7. Every Decade

8. Quarterly

9. Semi-Annually

10. Biennially

11. Once

12. Occasionally

CFR Citation(s) for the information collection under review (if applicable).

Title ___________________________________________________ Part _________ Section_________

Title ___________________________________________________ Part _________ Section_________

Title ___________________________________________________ Part _________ Section_________

Title ___________________________________________________ Part _________ Section_________

Information Collection Instruments – Send all instruments and any additional documents along with the Part 2 Form(s). If more than one Part 2 is completed make sure to identify which instruments are associated with which Part 2 form.

Federal Enterprise Architecture Business Reference Model (select one Services for Citizens Line of Business and one Sub-Function from its group)

Table 1: Federal Enterprise Architecture Business Reference Model

Services for Citizens Line of Business	Sub-Function
None
Community and Social Services	Homeownership Promotion Community and Regional Development Social Services Postal Service None
Correctional Activities	Criminal Incarceration Criminal Rehabilitation None
Defense and National Security	Strategic National and Theater Defense Operational Defense Tactical Defense None
Disaster Management	Disaster Monitoring and Predication Disaster Preparedness and Planning Disaster Repair and Restore Emergency Response None
Economic Development	Business and Industry Development Intellectual Property Protection Financial Sector Oversight Industry Sector Income Stabilization None
Education	Elementary, Secondary, and Vocational Education Higher education Cultural and Historic preservation Cultural and Historic Exhibition None
Energy	Energy Supply Energy Conservation and Preparedness Energy Resource Management Energy Production None
Environmental Management	Environmental Monitoring and Forecasting Environmental Remediation Pollution Prevention and Control None
General Science and Innovation	Scientific and Technological Research and Innovation Space Exploration and Innovation None
Health	Access to Care Population Health Management and Consumer Safety Health Care Administration Health Care Delivery Services Health Care Research and Practitioner Education None
Homeland Security	Border and Transportation Security Key Asset and Critical Infrastructure Protection Catastrophic Defense None
Income Security	General Retirement and Disability Unemployment Compensation Housing Assistance Food and Nutritonal Assistance Survivor Compensation None
Intelligence Operations	Intelligence Planning Intelligence Collection Intelligence Processing Intelligence Analysis and Production Intelligence Dissemination None
International Affairs and Commerce	Foreign Affairs International Development and Humanitarian Aid Global Trade None
Law Enforcement	Criminal Apprehension Criminal Investigation and Surveillance Citizen Protection Crime Prevention Leadership Protection Property protection Substance Control None
Litigation and Judicial Activities	Judicial Hearing Legal Defense Legal investigation Legal Prosecution and Litigation Resolution Facilitation None
Natural Resources	Water Resource Management Conservation, Marine, and Land management Recreational Resource Management and Tourism Agricultural Innovation and Services None
Transportation	Air transportation Ground Transportation Water Transportation Space Operations None
Workforce Management	Training and Employment Labor Rights Management Worker Safety None

Table 1 lists Services for Citizens Line of Business and Sub-Functions

Refer to http://www.whitehouse.gov/sites/default/files/omb/assets/fea_docs/FY10_Ref_Model_Mapping_QuickGuide_Aug_2008_Revised1.pdf

for Business reference Model categories.

Privacy Act System of Records (if applicable)

Title:      

Federal Register Citation

Volume       Page Number       Publication Date:      /     /      (mm/dd/yyyy)

Respondents

1. Total #2000

2. Small Entity #     

3. Percent Electronic 0

Affected Public

Individuals and Households

Private Sector

State, Local, or Tribal Governments

Federal Government

If affected Public is Private Sector check all the following that apply:

Business or other for-profits

Not-for-profits institutions

Farms

Frequency: How often on average will each respondent respond to the Information Collection?

Number of responses per respondent: 1

Time basis for each response:

1. Hour (24-7) – 8736 per year

2. Business Hour (40 per week) – 2080 per year

3. Day (7 per week)

4. Business Day (5 per week) – 260 per year

5. Week – 52 per week

6. Month – 52 per Month

7. Year

8. Decade

9. Quarter – 4 per year

10. Half-Year – 2 per year

Calculated: Annual Frequency = ______1_____ times per year (per respondent)

Calculated: Annual Number of responses = ________2000 a year

Per Response Hour and Cost Burden

Enter the hours and cost (per response) broken out by reporting, record keeping, and third-party disclosure.

Occupation: All

Mean hourly wage $22.33

Bureau of Labor Statistics: May 2012 National Occupational Employment and Wage Estimates, United States

http://www.bls.gov/oes/current/oes_nat.htm

Table 2: Hours and Cost Per Response

	Time Per Response	Hour Per Response	Annual Hour Burden	Cost Per Response	Annual Cost Burden
Reporting	5 minutes	0.083 hour	167	$1.85	$3700
Record Keeping
Third Party Disclosure
Total	5 minutes	0.083 hour	167	$1.85	$3700

Table 2 lists hours and costs

Annual Response and Burden

Table 3: Change in Burden

	Total Requested	Program Change Due to New Statute	Program Change Due to OPDIV/Office Discretion	Due to Adjustment in OPDIV/Office Estimate	Change Due to Violation	Currently Approved
Annual Responses	2000	2000
Annual Hour Burden	167 hours	167 hours	hours	hours	hours
Annual Cost Burden	$3700	$3700	$	$	$	$
Total

Table 3 lists Change in Burden Numbers

1