Generic Submission Form

Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

(OMB Control Number: 1601-0014)

T ITLE OF INFORMATION COLLECTION:

Base Ensemble Extended Wear Testing

PURPOSE:

The Department of Homeland Security (DHS), Science and Technology (S&T), First Responders Group’s (FRG), Responder Technologies (R-TECH) is requesting information from members of the First Responders Resource Group (FRRG) which include federal, local, state, and tribal governments. The responders represent multi disciplines: firefighters, police officers, and emergency medical services who will perform wear testing of the base ensemble garment in an operational environment for a period of ninety to one-hundred twenty days. Once the extended wear testing concludes, the First Responders will complete an independent assessment (i.e. questionnaire) regarding the operational use of the duty uniform via Survey Monkey. Upon release of the survey through the tool Survey Monkey, S&T will ensure that the IP address collection features will be turned off to avoid the collection of such information. This survey will not collect any PII. The responses will be aggregated by DHS/S&T/FRG/R-TECH for review. The Program Manager will share the response data obtained with the respective Project Performers and garment manufacturers.

DESCRIPTION OF RESPONDENTS:

The respondents are comprised of First Responders (fire, police, and emergency medical services from federal, local, state and tribal government). They will provide input regarding the overall design of a base ensemble garment or expressed an interest in assessing the unit during the annual S&T First Responders Resource Group (FRRG) Conference.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [x ] 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: Kimberli Jones-Holt_______________________________________

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [ x] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No

Gifts or Payments:

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

BURDEN HOURS

Type of Respondent	Form Name/Form Number	No. of Respondents	No. of Responses per Respondent	Avg. Burden per Response (in hours)**	Total Annual Burden (in hours)	Avg. Hourly Wage Rate*	Total Annual Respondent Cost
First Responders from Federal, State, local, or tribal governments	Base Ensemble Extended Wear Testing questionnaire	111	1	.50 (30 Minutes)	55.50	$33.40	$1,853.70
Totals		111			55.50		$1,853.70

NOTES ON HOUR BURDEN:
*  The above Average Hourly Wage Rate is the May 2016 Bureau of Labor Statistics average wage for “All Occupations” of $23.86 times the wage rate benefit multiplier of 1.4 (to account for fringe benefits) equaling $33.40. The selection of “All Occupations” (for example) was chosen as the expected respondents for this collection could be expected to be from any occupation.

FEDERAL COST: The estimated annual cost to the Federal government is $67,460.00.

The following method was used to estimate the cost (based on General Schedule Grade 14, step 10, WASHINGTON-BALTIMORE-NORTHERN VIRGINIA, DC-MD-VA-WV-PA locality, fully loaded annual pay of $145,629 with an hourly wage of $70.01: 1 personnel x 10% annual time (208 hours) = $14,562.

• Cost of 2 Teracore Client-Managers to review, analyze, and assimilate survey and responses with an hourly wage of $127.16:  2 personnel X 10% annual time (208 hours) = $52,898.

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? [x ] 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?

R-Tech conducts an annual FRRG meeting, providing First Responders the opportunity to discuss capability gaps and possible technological solutions that may bridge the identified gap. As gaps and solutions are defined, FRRG members volunteer to provide input on the concept design or participate in the assessment of the developed technology.

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

[ x ] Other, Explain Survey Monkey

2. Will interviewers or facilitators be used? [ x ] Yes [ ] 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 COLLECTION: 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 carefully. 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. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

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 Government. Only one type of respondent can be selected per row.

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.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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.

Submit all instruments, instructions, and scripts are submitted with the request.

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