Generic Clearance Template

Request for Approval under the "Generic Clearance for the Collection of
Routine Customer Feedback'^ (OMB Control Number; XXXX-YYYY)
TITLE OF INFORMATION COLLECTION:
Specially Designated Nationals (SDN) Survey
PURPOSE:
Collect information about the SDN consumer population; who they are, what SDN files they use,
why they use those particular files, how often they use them, and if there are any improvements
that can be made.

DESCRIPTION OF RESPONDENTS:
This is the SDN consumer population consisting of private businesses, govemment entities, and
individuals. This population uses the SDN lists for various reasons.

TYPE OF C O L L E C T I O N : (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 Govemment.
3. The collection is non-controversial and does not raise issues of concem to other federal
agencies.
4. The results are not intended to be disseminated to the public.
5. Infomiation gathered will not be used for the purpose of substantially informing influential
policy decisions.
6. The collection is targeted to the solicitation of opinionsfromrespondents who have
experience with the program or may have experience with the program in the future.
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To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Is personally identifiable infomiation (PII) collected? [ ] Yes [X] No
2. If Yes. is the information that will be collected included in records that arc subject to the
Privacy Act of 1974? [ ] Yes [ ] No

3. If Applicable, has a System or Records Notice been pubUshed? [ ] Yes [ ] No NOT
APPLICABLE
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
SDN Consumer Population

Participation
No. of
Respondents Time
10,000
5 min/survey

Burden
833.3 hrs

Totals
FEDERAL COST: The estimated annual cost to the Federal govemment is $204.00
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?
Customer List
[X] Yes
[ ] No
Sampling Plan
[ ] Yes
[X] 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?
We have a predefined email Ust, which currently receives the SDN update notifications. Our
survey results will come from this population, which consists of approximately 50,000 emails, of
which we're expecting a 20% response rate or 10,000 responses.
Within the survey there are questions that will allow for further analysis into the respondent
population.

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.

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 C O L L E C T I O N : 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 careftilly. 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 Govemment. 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.
F E D E R A L COST: Provide an estimate of the annual cost to the Federal govemment.
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.
Please make sure that all instruments, instructions, and scripts are submitted with the
request.