IC Template (REVISED)

Request for Approval under the “Generic Clearance for Qualitative Consumer Education, Engagement, and Experience Information Collections”

(OMB Control Number: 3170-0036)

1. TITLE OF INFORMATION COLLECTION:

2. PURPOSE:

3. DESCRIPTION OF RESPONDENTS:

4. TYPE OF COLLECTION (Administration of the instrument):

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media [ ] Telephone

[ ] In-person [ ] Mail

[ ] Small Discussion Group [ ] _{Focus Group} [ ] Other, Explain ______________________

2. Will interviewers or facilitators be used?

[ ] Yes [ ] No [ ] Not Applicable

5. Focus group or survey:

If you plan to conduct a focus group or survey, please provide answers to the following questions:

a. 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 [ ] Not Applicable

b. If the answer is yes, please provide a description below. 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?

5. Information Collection Procedures

Please summarize the procedures that will be used to collect data from respondents.

5. 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 [ ] Not Applicable

If applicable, what is the link the Privacy Impact Assessment (PIA)?

3. If Applicable, has a System or Records Notice (SORN) been published?

[ ] Yes [ ] No [ ] Not Applicable

If applicable, what is the Federal Register citation for the SORN? __ FR ________.

5. INCENTIVES:

1. Is an incentive provided to participants? [ ] Yes [ ] No

2. If Yes, provide the amount or value of the incentive? $___________.

3. If Yes, provide a statement justifying the use and amount of the incentive.

5. Assurances of Confidentiality:

1. Will a pledge of confidentiality be made to respondents? [ ] Yes [ ] No

2. If Yes, please cite the statue, regulation, or contractual terms supporting the pledge.

5. JUSTIFICATION OF SENSITIVE QUESTIONS (if applicable):

5. BURDEN HOURS:

Category of Respondent	Number of Respondents	Frequency	Number of Responses	Response Time (hours)	Burden (hours)
[Insert rows as needed]
Totals

12. FEDERAL COST: The estimated annual cost to the Federal government is $________.

13. CERTIFICATION:

By submitting this document, the Bureau certifies the following to be true:

• The collection is voluntary.

• The collection is low-burden for respondents.

• The collection is non-controversial and does not raise issues of concern to other federal agencies.

• Information gathered will not be used for the purpose of substantially informing influential policy decisions.

• The collection is not statistically significant; the results are not intended to be generalizable beyond the survey population.

• The results will not be used to measure regulatory compliance or for program evaluation.

Instructions

(will be deleted prior to submission to OMB)

1. TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Community Education Project Librarian and Patron Interviews)

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 that are all related, you only need to complete one form. If you are requesting approval for multiple unrelated collections then you must complete a form for each instrument.

5. Focus Groups or Survey: If you are conducting a focus group or survey please provide answers to the following questions:

1. Identify if you have or will have a list of potential respondents (e.g., conference participants).

2. 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.

6. INFORMATION COLLECTION PROCEDURES: Please summarize the procedures that will be used to collect data from respondents.

7. Personally Identifiable Information (PII): Provide answers to the questions. Also, if PII will be collected, please consult with the Bureau’s Privacy office before submitting this request to the PRA Team. If applicable, provide a link to the Privacy Impact Assessment (PIA) and the System of Records Notice (SORN) citation should provide the title and Federal Register citation.

8. INCENTIVES: An incentive is defined as a positive motivational influence; something that induces action or motivates effort. Incentives are most appropriately used in Federal statistical surveys with hard-to-find populations or respondents whose failure to participate would jeopardize the quality of the survey data. More information on the use of incentives, please see OMB’s “Guidance on Agency Survey and Statistical Information Collections” (pages 68-70). This guidance is available on OMB’s website at http://www.whitehouse.gov/sites/default/files/omb/assets/omb/inforeg/pmc_survey_guidance_2006.pdf. If you answer yes to the question regarding incentives, please describe the incentive and provide a justification for the use of an incentive as well as the amount.

9. ASSURANCES OF CONFIDENTIALITY: If an assurance of confidentiality is provided, please cite the authority for such a pledge.

10. JUSTIFICATION OF SENSITIVE QUESTIONS: Please provide a justification for asking questions that could be considered sensitive in nature (e.g., age, gender, sexual orientation, income, religion, etc.)

11. BURDEN ESTIMATES:

Category of Respondents: List the individual collections that you are requesting to be approved under this request. For example, phone survey, web survey, training materials evaluation, conference feedback.

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. This estimate should be expressed as hours. Please round to the nearest whole hour.

12. FEDERAL COST: Provide an estimate of the annual cost to the Federal government for conducting the information collection. Do NOT include costs that the Bureau would incur even without the collection.

13. CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Template Paperwork Act Statement (to be placed on collection instrument(s) either at the bottom of the first or last page)

Paperwork Reduction Act

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The OMB control number for this collection is 3170-0036. It expires on 06/30/2016. The time required to complete this information collection is estimated to average approximately [## minutes / hours] per response, including the time for reviewing any instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Responding to this collection of information is voluntary. Comments regarding this collection of information, including the estimated response time, suggestions for improving the usefulness of the information, or suggestions for reducing the burden to respond to this collection should be submitted to Bureau at the Consumer Financial Protection Bureau (Attention: PRA Office), 1700 G Street NW, Washington, DC 20552, or by email to [email protected].

Paper Forms: The information is included either on the form, questionnaire, as part of the instructions, or in a cover letter or memorandum that accompanies the collection of information. The following should appear at the top right corner of all paper forms and surveys.

OMB No. 3170-0036

Expiration Date: 06/30/2016

Electronic Forms: The information is included either in the instructions, near the title of electronic collection instrument, or for on-line applications, on the first screen viewed by the respondent. This information can also be provided in a separate window with a link titled, “Paperwork Reduction Act Statement”.

Sample Privacy/Confidentiality Statements – USE ONLY IF APPLICABLE

[Standard CFPB Statement]

The Bureau will not disclose any personally identifiable information collected except to the extent that it is required to do so by law and as provided in the Privacy Act Statement listed below. Additionally, the Bureau will treat the information collected consistent with its confidentiality regulations at 12 C.F.R. Part 1070, et seq.

[Sample statement for when there is no legal authority for a pledge of confidentiality]

Privacy: Responses to this data collection will be used only for statistical purposes. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific organization or individual. We will not provide information that identifies you or your affiliation to anyone outside the study team, except as required by law.

Note: The above language is provided by the Office of Management and Budget’s Statistical and Science Policy office for studies where there was no real statutory basis for the agency to protect the confidentiality of respondents—This doesn’t mean that the agency would not resist providing identifiable information and would seek to provide aggregate nonidentifiable information that would help serve whatever purpose the information was requested for; however, the agency could be legally compelled to provide identifiable information. This statement is not intended to replace any required Privacy Act statements.

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Please make sure that all instruments, instructions, and scripts are submitted with the request

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