Generic Clearance Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 1800-0011)

TITLE OF INFORMATION COLLECTION: White House Initiative on Educational Excellence for Hispanics - Postsecondary Access and Completion for All: Latinas/os in America’s Future Symposium Participant Survey

PURPOSE:

To collect feedback about the symposium from the participants regarding the panels and event logistics

DESCRIPTION OF RESPONDENTS:

Stakeholders: Individuals – non-profit leaders, teachers, practitioners, students, and staff of government officials. This is for attendees of the symposium (approx. 100)

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form  Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[] Focus 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 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.

Name:__Emmanuel Caudillo______________________________________________

To assist review, please provide answers to the following question:

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

3. If Applicable, has a System or Records Notice been published? [ ] Yes  No

Gifts or Payments:

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

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals	100	10 minutes	17 hrs
Totals

FEDERAL COST: The estimated annual cost to the Federal government is: $0

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? [ ] Yes [ ] 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?

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

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes  No

3