omb83-i for 2015 Census Test

PAPERWORK REDUCTION ACT SUBMISSION
Please read the instructions before completing this form. For additional forms or assistance in completing this form, contact your
agency's Paperwork Clearance Officer. Send two copies of this form, the collection instrument to be reviewed, the Supporting
Statement, and any additional documentation to: Office of Information and Regulatory Affairs, Office of Management and Budget,
Docket Library, Room 10102, 725 17th Street NW, Washington, DC 20503.
2. OMB CONTROL NUMBER

1. AGENCY/SUBAGENCY ORIGINATING REQUEST

Department of Commerce
Bureau of the Census
Decennial Management Division

a.

0607

4. TYPE OF REVIEW REQUESTED (X one)

3. TYPE OF INFORMATION COLLECTION (X one)

x

x

b. NONE

x

a. NEW COLLECTION

a. REGULAR SUBMISSION
b. EMERGENCY - APPROVAL REQUESTED BY:

b. REVISION OF A CURRENTLY APPROVED COLLECTION

c. DELEGATED

c. EXTENSION OF A CURRENTLY APPROVED COLLECTION
d. REINSTATEMENT, WITHOUT CHANGE, OF A PREVIOUSLY
APPROVED COLLECTION FOR WHICH APPROVAL HAS EXPIRED

5. SMALL ENTITIES
Will this information collection have a significant economic
impact on a substantial number of small entities?

e. REINSTATEMENT, WITH CHANGE, OF A PREVIOUSLY
APPROVED COLLECTION FOR WHICH APPROVAL HAS EXPIRED

YES
NO
x
6. REQUESTED EXPIRATION DATE
a. THREE YEARS FROM APPROVAL DATE

f. EXISTING COLLECTION IN USE WITHOUT AN OMB CONTROL
NUMBER

x

b. OTHER:

03

31

2016

7. TITLE

2015 Census Test
8. AGENCY FORM NUMBER(S) (if applicable)
See attached list
9. KEYWORDS

10. ABSTRACT
The 2015 Census Test is needed to help find ways to reduce cost, increase self-response, and leverage new data collection alternatives while maintaining high quality
results. The results of the 2015 Census Test will help guide the design of additional 2020 Census testing later this decade. The collection of data targets households
and individuals.

11. AFFECTED PUBLIC (Mark primary with "P" and all others that apply with "X")
P

12. OBLIGATION TO RESPOND (Mark primary with "P" and all

others that apply with "X")

a. INDIVIDUALS OR HOUSEHOLDS

d. FARMS

a. VOLUNTARY

b. BUSINESS OR OTHER FOR-PROFIT

e. FEDERAL GOVERNMENT

b. REQUIRED TO OBTAIN OR RETAIN BENEFITS

P c. MANDATORY
x f. STATE, LOCAL OR TRIBAL GOVERNMENT
13. ANNUAL REPORTING AND RECORDKEEPING HOUR BURDEN
14. ANNUALIZED COST TO RESPONDENTS (In thousands of dollars)
c. NOT-FOR-PROFIT INSTITUTIONS

a. NUMBER OF RESPONDENTS
b. TOTAL ANNUAL RESPONSES
(1) Percentage of these responses collected electronically
c. TOTAL ANNUAL HOURS REQUESTED
d. CURRENT OMB INVENTORY
e. DIFFERENCE (+, -)
f.

EXPLANATION OF
DIFFERENCE:

(1) Program change (+, -)

470,000
470,000
70
98,086
0
98,086
98,086

a. TOTAL CAPITAL/STARTUP COSTS
c. TOTAL ANNUALIZED COST REQUESTED
d. CURRENT OMB INVENTORY
e. DIFFERENCE (+, -)
f.

16. FREQUENCY OF RECORDKEEPING OR REPORTING (X all that apply)

"P" and all others that apply with "X")

c. GENERAL PURPOSE STATISTICS
d. AUDIT

17. STATISTICAL METHODS
Does this information collection employ
statistical methods?
x

YES

OMB FORM 83-I, 10/95

a. RECORDKEEPING

P

NO

x

20.00

(2) Adustment (+, -)

15. PURPOSE OF INFORMATION COLLECTION (Mark primary with

b. PROGRAM EVALUATION

EXPLANATION OF DIFFERENCE:
(1) Program change (+, -)

(2) Adustment (+, -)

a. APPLICATION FOR BENEFITS

0.00
20.00
0.00
0
20

b. TOTAL ANNUAL COSTS (O&M)

e. PROGRAM PLANNING
OR MANAGEMENT
f. RESEARCH
g. REGULATORY OR
COMPLIANCE

x

b. THIRD PARTY DISCLOSURE

c. REPORTING:
(1) On Occasion

(2) Weekly

(3) Monthly

(4) Quarterly

(5) Semi-Annually

(6) Annually

(7) Biennially

(8) Other (Describe) one-time

18. AGENCY CONTACT (Person who can best answer questions regarding the content of this
submission)
a. NAME

Erin Love

b. TELEPHONE NUMBER (Include area code)

(301) 763-2034

OMB CONTROL NUMBER

TITLE

2015 Census Test
19. CERTIFICATION FOR PAPERWORK REDUCTION ACT SUBMISSIONS
a. PROGRAM OFFICIAL CERTIFICATION (Internal DOC Use Only)
Type name

Date

Nancy A. Potok, Deputy Director and Chief Operating Officer
Mark E. Doms, Under Secretary for Economic Affairs

On behalf of this Federal agency, I certify that the collection of information encompassed by this request
complies with 5 CFR 1320.9.
NOTE: The text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320.8(b)(3), appear at the end of the
instructions. The certification is to be made with reference to those regulatory provisions as set forth in the
instructions.
The following is a summary of the topics, regarding the proposed collection of information, that the
certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8(b)(3) about:
(i)

Why the information is being collected;

(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective
management and use of the information to be collected (see note in Item 19 of the instructions);
(i) If applicable, it uses effective and efficient statistical survey methodology; and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item below and explain the
reason in Item 18 of the Supporting Statement.

b. SENIOR OFFICIAL OR DESIGNEE CERTIFICATION
Type name

Jennifer Jessup, Departmental Paperwork Clearance Officer
OMB FORM 83-I (BACK), 10/95

Date