IC Submission Template

CONSUMER FINANCIAL PROTECTION BUREAU
REQUEST FOR APPROVAL UNDER THE GENERIC CLEARANCE
FOR CONSUMER COMPLAINT AND INFORMATION COLLECTION SYSTEM
(TESTING AND FEEDBACK)
(OMB Control Number: 3170-00XX)

1. TITLE OF INFORMATION COLLECTION:

2. PURPOSE:

3. DESCRIPTION OF RESPONDENTS:

4. TYPE OF COLLECTION: (Check all that apply)
[ ] Customer Satisfaction Survey [ ] Piloting Revisions to Consumer Complaint Form
[ ] Focus group
[ ] Usability or laboratory test (not in live system)
[ ] Web-based
[ ] Other (describe) ___________________
5. PERSONALLY IDENTIFIABLE INFORMATION:
a. Is personally identifiable information (PII) collected? [ ] Yes [ ] 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 [ ] Not Applicable
c. If Applicable, has a System or Records Notice been published?
[ ] Yes [ ] No [ ] Not Applicable
If yes, please provide Federal Register citation. __ FR _______.

6. GIFTS OR PAYMENTS:
Incentives will not be offered to respondents responding to the collections of information
approved under this generic information collection plan.

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7. BURDEN HOURS:
Category of Respondent

Number of
Respondents

Participation
Time

Burden

[Insert rows as needed]
Totals

8. FEDERAL COST: The estimated annual cost to the Federal government is $ ____________
9. DURATION OF TEST:

10. CERTIFICATION:
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.
 Information gathered will not be used solely 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.
 Test questions will not exceed the durations specified herein and will only be made
permanent through standard clearance procedures.

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Instructions
1. 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)
2. 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.
3. 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.
4. TYPE OF COLLECTION: Check all that apply. If you are requesting approval of other
instruments under the generic, you must complete a form for each instrument.
5. PERSONALLY IDENTIFIABLE INFORMATION: Provide answers to the questions.
Any request that includes collecting information about individuals must be reviewed by the
CFPB Privacy office prior to submission to OMB.
6. GIFTS OR PAYMENTS: If you answer yes to the question, please describe the incentive
and provide a justification for the amount.
7. 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. Please round to the nearest whole number.
8. FEDERAL COST: Provide an estimate of the annual cost to the Federal government.
9. DURATION OF TEST: Specify for how long and/or for how many response the test
questions will be conducted (e.g., 3,000 responses and not to exceed 60 days).
10. CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the
collection will be returned as improperly submitted or it will be disapproved.

Please make sure that all instruments, instructions, and scripts are submitted with the
request; including, as applicable, a list of questions to be tested.

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