IC Submission Template

Request for Approval under the GENERIC CLEARANCE FOR CFPB OFFICE OF
INTERGOVERNMENTAL AFFAIRS OUTREACH ACTIVITIES

(OMB Control Number: 3170-XXXX)

TITLE OF INFORMATION COLLECTION:
PURPOSE:

DESCRIPTION OF RESPONDENTS:

TYPE OF COLLECTION: (Check all that apply)
[ ] In-Person Meeting
[ ] Interview
[ ] Focus Group
[ ] Social Media Poll

[ ] Qualitative Survey
[ ] Small Discussion Group
[ ] Online Discussion Forum
[ ] Data Sharing
[ ] 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.

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Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [ ] 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 [ ] N/A
3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No [ ] N/A

Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to
participants? [ ] Yes [ ] No

Assurances of Confidentiality:
1. Will a pledge of confidentiality be made to respondents? [ ] Yes [ ] No [ ] N/A
2. If Yes, please cite the statue, regulation, or contractual terms supporting the pledge.

BURDEN HOURS
Category of Respondent

Number of
Respondents

Participation
Time

Burden

Totals

FEDERAL COST: The estimated annual cost to the Federal government: $___________

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If you are conducting a focus group, interviews, 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?
[ ] Yes [ ] No [ ] N/A
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?

Note: All instruments, instructions, and scripts are submitted with this request.

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