Fast Track Short Form

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 2700-0153)
TITLE OF INFORMATION COLLECTION: The 2016 NASA Ombudsman Program User
Survey
PURPOSE: It is NASA's policy to provide civil servants, Center contractor workforce, and
other individuals (e.g., partners, customers) working in or on a NASA-controlled facility with an
informal, independent, confidential, and neutral channel to communicate and facilitate resolution
of issues and concerns related to safety, organizational performance, or mission success without
fear of retribution.
This information collection provides an opportunity for NASA on-site contractors to share
information related to their experience with the NASA Ombudsman Program and/or their
awareness of this important NASA program. Responses are not tracked back to the responder.
The results will not be shared with the public.
The survey will be conducted via Survey Monkey.

DESCRIPTION OF RESPONDENTS: NASA contractors with an active NASA email
address.
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: Fatima Johnson, Esq.Executive Officer, NASA Office of Strategic Infrastructure

To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [x ] No

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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

Participation
Time

Burden

Individuals

1500

7.5 minutes

187.5 hours

Totals

1500

7.5 minutes

187.5 hours

FEDERAL COST: The estimated annual cost to the Federal government is $300, which
reflects the price of one year license for access to the SurveyMonkey tool.
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?
NASA on-site contractors with an active NASA email address
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
[ ] In-person
[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ ] Yes [ x ] No

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