General Clearance Submission Template

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

TITLE OF INFORMATION COLLECTION: Soliciting feedback from customers

PURPOSE: As part of the Access Board’s efforts to assess the performance of its compliance and enforcement program, the agency is proposing to collect feedback from citizens on their satisfaction with the agency’s performance and program outcomes. We plan on including this customer feedback to the Board, with any findings and recommendations for changes to how we run the program, with our annual report on compliance program performance.

DESCRIPTION OF RESPONDENTS: The Access Board proposes to collect comments from participants at public meetings, and survey all individuals submitting complaints to the Access Board where the Access Board completed all final action on the complaint during a given fiscal year.

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 [x ] Other: comment cards and customer surveys

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: Lisa Fairhall

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, 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 [x ] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individual	1,100	0.094 hr	103 hours
Total	1,100/ year		103 hrs/year

FEDERAL COST: The estimated annual cost to the Federal government is less than $5,000. This represents the cost of staff time associated with reading and analyzing responses, and the cost of printing and mailing surveys, and the cost of including self-addressed stamped envelopes for respondents’ use.

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?

The Access Board proposes to include a survey form with the final “closing” letter transmitted to each complainant from the Access Board – letters notifying either that corrective action has been completed to remove barriers the complainant identified in a complaint to the Access Board, or that after investigation we determined that the Board either had no jurisdiction over the matters raised in the complaint, or found no violation. A self addressed stamped envelope will be provided. This will give all complainants an opportunity to provide feedback to the Board, whether their complaints were ultimately referred to another agency for handling, or resolved under the Access Board program. Completion of the surveys will be completely voluntary and respondents may remain anonymous or include contact information, at their discretion. We do not plan to conduct any follow-up with respondents. Results will be recorded manually by Access Board staff as they are received, and periodically compiled for analysis.

In addition, the Access Board intends to distribute comment cards to participants at select public hearings and information meetings conducted by the Access Board, to solicit feedback from participants regarding their experience at the event.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ x] In-person

[ x] 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.