AttC Wrksht2 ATSDR Customer Satisfaction Survey

AttC Wrksht2 ATSDR Customer Satisfaction Survey.docx

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

AttC Wrksht2 ATSDR Customer Satisfaction Survey

OMB: 0923-0047

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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

  1. Annual Responses

2000

2000





  1. Annual Hour Burden

167 hours

167 hours

hours

hours

hours


  1. Annual Cost Burden

$3700

$3700

$

$

$

$

Total







Table 3 lists Change in Burden Numbers


1


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePAPERWORK REDUCTION ACT SUBMISSION WORKSHEET PART 2
SubjectPart 2: Information Collection Details
AuthorU.S. Department of Health and Human Services
File Modified0000-00-00
File Created2021-01-29

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