Signed Generic Clearance Application

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 1660-0130)
TITLE OF INFORMATION COLLECTION: DisasterAssistance.gov Customer
Satisfaction Survey, FEMA Form 519-0-17
PURPOSE: Collect feedback from DisasterAssistance.gov users to determine the overall
satisfaction rating for the website, which is required for data calls and partner reporting. Additional
answers and comments are used to make and prioritize website changes for the Disaster Assistance
Re-Engineering Project (DARE) taking place over the next few years.
Due to system constraints, three different surveys are being implemented. Surveys are tailored to
the process the user completed:
 10% of users submitting a FEMA application will be invited to take the RI Survey
(questions about applying for assistance) at the end of the application process
 10% of users creating an account to check their application status will be invited to take
the AI Survey (questions about checking an application status and creating an account) at
the end of the process to create the account
 The ‘general’ survey will be available at all times on the non-application/information
pages of the website and can be taken by anyone, no matter the path taken during the
application and/or account creation process.
DESCRIPTION OF RESPONDENTS:
Disaster survivors using DisasterAssistance.gov
TYPE OF COLLECTION: (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 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:

Annamarie M. Mrazik

ANNAMARIE
M MRAZIK

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Digitally signed by ANNAMARIE M MRAZIK
DN: c=US, o=U.S. Government,
ou=Department of Homeland Security,
ou=FEMA, ou=People, cn=ANNAMARIE M
MRAZIK,
0.9.2342.19200300.100.1.1=0132949968.FEMA
Date:2015.12.2309:48:23-05'00'

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
Category of Respondent

No. of
Respondents
Average of 3500/yr
depending on disaster activi y

Individuals or Households
Totals

3500/yr

Participation
Time
15 minutes

15 minutes

Burden
875

875

Burden Hours - Details
o AI Survey – 2,000
o RI Survey – 800
o General Survey – 700
 Original estimate of 3500 was based on the average number of survey
responses for the previous 3 years (2012, 2013, 2014)
 Data from 2015 has been used to provide an estimate for each of the
surveys
FEDERAL COST: The estimated annual cost to the Federal government is $8273
o Approximately 10% of a government employee’s time is spent working with the
survey data including categorizing, tracking, and analyzing the survey results.
 The Federal Cost is an average and could increase/decrease depending on
the yearly disaster activity and data call requests
 The amount was determined using the following formula:
59,000 (GS-9 average pay Step 5)
X 10% (time spent working with data)
X 1.4% (fully burdened salary)
= 8273
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 [x] No
If the answer is yes, please provide a description of both below (or attach the sampling
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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) [x] Web-based or other forms of Social
Media
[ ] Telephone
[ ] Inperson [
] 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 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
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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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