Generic IC submission Template

REQUEST FOR APPROVAL UNDER THE “GENERIC INFORMATION
COLLECTION PLAN TO CONDUCT COGNITIVE RESEARCH AND
PILOT TESTING” (OMB CONTROL NUMBER: 3170-00XX)

PART A. GENERAL INFORMATION

1. Title of the Information Collection (Study):
2. Study Abstract:

3. Type of Collection:
a.

Will there be an informed consent? [ ] Yes [ ] No [ ] N/A
Explain why or why not an informed consent is being used.

b.

How will you collect the information? (Check all that apply)
[ ] Cognitive Laboratory Study

[ ] Pilot Testing

[ ] Other, Explain ______________________
c.

Will interviewers or facilitators be used? [ ] Yes [ ] No [ ] N/A

4. Personally Identifiable Information:
a. Is personally identifiable information (PII) collected? [ ] Yes [ ] No
1. If yes, explain direct identifying PII and/or other PII and relevant uses.
b. If Yes, is the information that will be collected included in records that are subject to the
Privacy Act of 1974? [ ] Yes [ ] No [ ] Not Applicable
1. If Applicable, has a System or Records Notice (SORN) been published?
[ ] Yes [ ] No
2. If Yes, provide SORN title and Federal Register citation for the SORN __ FR ______
Title: __________________________________________________________________.
c. 1. Has the Privacy Impact Assessment (PIA) been published?
[ ] Yes [ ] No [ ] Not Applicable
2. If Yes, provide link to PIA. If No, please describe that status of the PIA.:

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PART B. JUSTIFICATION

1. Purpose of the Study and Intended Uses of the Data:

2. Payments or Gifts (Incentives) to Respondents:

3. Assurances of Confidentiality and Justification for Sensitive Questions:

4. Estimated Burden of Information Collection:
Information Collection

No. of
Respondents

Frequency
(Response
per
Respondent)

//////////////////

////////////////

Total
Annual
Responses

Average
Response
Time
(hours)

Total
Burden
Hours

[Delete or insert rows as needed]
Totals:

5. Federal Costs (estimated annual cost to the Federal government):

///////////////

$

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PART C. STATISTICAL METHODS

1. Respondent Universe and Selection Methods:

2. Information Collection Procedures:

3. Testing of Procedures or Methods:

4. Contact Information for Statistical Aspects of the Design:

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PART D. CERTIFICATION PURSUANT TO 5 CFR 1320.9, AND THE RELATED
PROVISIONS OF 5 CFR 1320.8(b)(3) :
By submitting this document, the Bureau certifies the following to be true:
(a)
(b)
(c)
(d)
(e)
(f)

(g)
(h)
(i)

It is necessary for the proper performance of agency functions;
It avoids unnecessary duplication;
It uses plain, coherent, and unambiguous terminology that is understandable to respondents;
Its implementation will be consistent and compatible with current reporting and recordkeeping
practices;
It indicates the retention period for recordkeeping requirements;
It informs respondents of the information called for under 5 CFR 1320.8(b)(3):
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
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;
It uses effective and efficient statistical survey methodology; and
It makes appropriate use of information technology.

PART E. CERTIFICATION FOR INFORMATION COLLECTIONS SUBMITTED UNDER A
GENERIC INFORMATION COLLECTION PLAN
(a)
(b)
(c)
(d)

(e)
(f)
(g)
(h)

The collection is voluntary.
The collection is low-burden for respondents and low-cost for the Federal Government.
The collection is non-controversial and does not raise issues of concern to other federal agencies.
The collection is not intended to be published to the public as an official government statistic to
be externally valid and representative of a population of interest. The results are intended to be
internally valid, not necessarily externally valid.
Information gathered will not be used for the purpose of substantially informing influential policy
decisions.
The collection is targeted to the solicitation of opinions from respondents who have experience
with the topics or issues being studied.
The results will not be used to measure regulatory compliance or for CFPB program performance
evaluation.
The results are not intended to be generalizable or otherwise draw inferences beyond the survey
population.

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Instructions
(will be deleted prior to submission to OMB)

PART A. GENERAL INFORMATION
1. Title of the Information Collection (Study): Provide the name of the collection/study that is the
subject of the request. The Title should be succinct and how you want it inventoried in OMB’s system
which is publically available.
2. Study Abstract: Provide a brief description of this collection of information; including a description
of respondents, what information is collected, why it is collected, and how it will be used.
3. Type of Collection: Check all that apply. If requesting approval of other instruments under the
generic that are all related, you only need to complete one form. If you are requesting approval for
multiple unrelated collections then you must complete a form for each instrument.
4. Personally Identifiable Information (PII): Provide answers to the questions. The CFPB Privacy
Office is available to assist in providing the information needed for completing this section.

PART B. JUSTIFICATION
1. Purpose of the Study and Intended Uses of the Data: 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.
2. Payments or Gifts (Incentives) to Respondents: Explain any decision to provide any payment or gift to
respondents, other than remuneration of contractors or grantees. If such a decision is contemplated, include
a justification for this action, description, monetary value of the item. Please note that as a general rule of
thumb, OMB will not approve incentives that exceed $40 for a lab study or $50 to $75 (depending on time
commitment) for a focus group. The justification for the use of an incentive must be tied to the ability to
recruit the desired respondent pool as well as to obtaining sufficient response rates. It is also helpful to
reference similar studies and cite pertinent literature.
An incentive is defined as a positive motivational influence; something that induces action or motivates
effort. Incentives are most appropriately used in Federal statistical surveys with hard-to-find populations or
respondents whose failure to participate would jeopardize the quality of the survey data. More information
on the use of incentives, please see OMB’s “Guidance on Agency Survey and Statistical Information
Collections” (pages 68-70). This guidance is available on OMB’s website at
http://www.whitehouse.gov/sites/default/files/omb/assets/omb/inforeg/pmc_survey_guidance_2006.pdf. If you
answer yes to the question regarding incentives, please describe the incentive and provide a justification for
the use of an incentive as well as the amount.
3. Assurances of Confidentiality and Justification for Sensitive Questions: Describe any assurance of
confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency
policy. If the CFPB has unique confidentiality policies or other privacy policies apply, they should be cited
and discussed in terms of what protections will be provided to respondents. Also discuss if respondents will
be asked to sign an informed consent and if not, explain here.
Explain the type of notice that is provided to an individual regarding their use of their information. Notice
typically is provided through a Privacy Act Statement, a Privacy Notice or a modified Privacy Notice. The
CFPB provides a Privacy Act Statement, as required by the Privacy Act of 1974, when information is
collected from Respondents either by the CFPB or by contractors acting on behalf of the CFPB, and the
information will be retrieved by personal identifier. The Privacy Act Statement is generally provided during
recruitment, when individuals provide information demonstrating that they meet the selection criteria, (e.g.,
race/ethnicity, age, income, gender, etc.) and contact information (e.g., name, email, phone number,
address) in order to facilitate scheduling and administration of Field and Lab Studies. In the case of mail or
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web surveys that are not conducted in person, the Privacy Act Statement is generally provided with the
survey instrument. When the Privacy Act does not apply, the CFPB provides Respondents with a Privacy
Notice– for example, when the CFPB contracts with a third party to conduct Field and Lab Studies and that
third party already maintains information on Respondents as part of an existing pool of volunteers. When a
Privacy Act Statement is not required and when the provision of a complete Privacy Notice could
undermine the validity of the Field and Lab Studies, a modified Privacy Notice may be provided.
4. Estimated Burden of Information Collection:
- Information of Collection. Identify the information collection activity.
- Number of Respondents. Provide an estimate of the number of respondents.
- Frequency (Responses per Respondent). Enter how often respondents will respond to this collection
(e.g., 1x, monthly, annually, semiannually, etc.)
- Number of Annual Responses. Provide an estimate for the total number of responses (e.g., number of
respondents x responses).
- Average Response Time: Provide an estimate of the amount of time required for a respondent to respond
to the data request(s). Express this time in hours (no more than two decimals).
- Total Burden Hours. Provide the total annual burden hours: Multiply the Number of responses and the
average response time. This estimate
should be expressed as hours. Please round to the nearest whole
hour.
5. Federal Costs (estimated annual cost to the Federal government): Provide an estimate of the annual
cost to the Federal government for conducting the information collection. Do NOT include costs that the
Bureau would incur even without the collection.

PART C. STATISTICAL METHODS
1. Respondent Universe and Selection Methods: Describe (including a numerical estimate) the potential
respondent universe and any sampling or other respondent selection method to be used. Data on the
number of entities (e.g., establishments, State and local government units, households, or persons) in the
universe covered by the collection and in the corresponding sample are to be provided in tabular form for
the universe as a whole and for each of the strata in the proposed sample. Indicate expected response rates
for the collection as a whole. If the collection had been conducted previously, include the actual response
rate achieved during the last collection.
The response should describe how that universe was or will be selected. The method of sampling should
also be explained. With respect to the response rate, the narrative should cover the actual percentage
response rate that is anticipated. Additionally, you should describe the efforts that will be undertaken to
ensure a high response rate, including pre-survey telephone calls or correspondence, post-mailing
reminders, etc. If correspondence will be used to boost response rates, copies of all letters, telephone scripts
or other materials should be included in the package. If the collection has been conducted previously, you
should provide a summary of that activity, including the response rate achieved.
2. Information Collection Procedures: Describe the procedures for the collection of information
including:
*
Statistical methodology for stratification and sample selection,
*
Estimation procedure,
*
Degree of accuracy needed for the purpose described in the justification,
*
Unusual problems requiring specialized sampling procedures, and
*
Any use of periodic (less frequent than annual) data collection cycles to reduce burden.
Where a collection is ongoing – i.e. has been conducted previously and is continuing for the
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foreseeable future – a description of any changes that have been made in the procedures or statistical
methodology of the collection since the last approval should be discussed.
3. Testing of Procedures or Methods: Describe methods to maximize response rates and to deal with
issues of non-response. The accuracy and reliability of information collected must be shown to be adequate
for intended uses. For collections based on sampling, a special justification must be provided for any
collection that will not yield "reliable" data that can be generalized to the universe studied.
This question is somewhat redundant of a portion of question B.1. You should include a more thorough
discussion of your plan of action for dealing with non-response. If the collection is qualitative and does not
necessarily employ a sampling frame or other proven statistical methods, an explanation of exactly what
practical utility the collection will have for the agency must be discussed. The discussion should include a
listing of the specific uses you contemplate for the data collected.

4. Contact Information for Statistical Aspects of the Design: Provide the names and telephone numbers
of individuals consulted on statistical aspects of the design and the name of the agency unit, contractor(s),
grantee(s), or other person(s) who will actually collect and/or analyze the information for the agency.]
[OMB-OIRA has produced a number of documents that may serve as useful reference material for
completing this Part. These can be found at:
http://www.whitehouse.gov/omb/inforeg_statpolicy

PARTS D. and E. CERTIFICATIONS:
Please read the certifications carefully. If you incorrectly certify, the collection will be returned as
improperly submitted or it will be disapproved. Generally, the Bureau’s PRA Officer does not
certify information collection requests seeking an exemption to the PRA certification requirements.
Any exemption to the certifications in Part D must be fully justified. No exemptions under the
certifications in Part E will be allowed under this generic information collection plan.

PLEASE MAKE SURE THAT ALL INSTRUMENTS, INSTRUCTIONS, AND SCRIPTS
ARE SUBMITTED WITH THE REQUEST

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INSTRUCTIONS FOR DISPLAYING CERTAIN PRA-REQUIRED INFORMATION
FOLLOWS
Template Paperwork Act Statement (to be placed on collection instrument(s) either at the bottom of
the first or last page)
Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless it displays a valid OMB
control number. The OMB control number for this collection is 3170-00XX. It expires on
XX/XX/20XX. The time required to complete this information collection is estimated to average
approximately [## minutes / hours] per response. Responding to this collection of information is
voluntary. Comments regarding this collection of information, including the estimated response
time, suggestions for improving the usefulness of the information, or suggestions for reducing the
burden to respond to this collection should be submitted to Bureau at the Consumer Financial
Protection Bureau (Attention: PRA Office), 1700 G Street NW, Washington, DC 20552, or by
email to [email protected].

Paper Forms: The information is included either on the form, questionnaire, as part of the
instructions, or in a cover letter or memorandum that accompanies the collection of information.
The following should appear at the top right corner of all paper forms and surveys.
OMB No. 3170-00XX
Expiration Date: XX/XX/20XX
Electronic Forms: The information is included either in the instructions, near the title of electronic
collection instrument, or for on-line applications, on the first screen viewed by the respondent. This
information can also be provided in a separate window with a link titled, “Paperwork Reduction Act
Statement”.
Sample Confidentiality Statements – USE ONLY IF APPLICABLE (Consult with the Bureau’s
Privacy Office)
[Standard CFPB Confidentiality Statement]
The Bureau will not disclose any personally identifiable information collected except to the extent that it is
required to do so by law and as provided in the Privacy Act Statement listed below. Additionally, the
Bureau will treat the information collected consistent with its confidentiality regulations at 12 CFR Part
1070, et seq.
[Sample statement for when there is no legal authority for a pledge of confidentiality]

Responses to this data collection will be used only for statistical purposes. The reports prepared for this
study will summarize findings across the sample and will not associate responses with a specific
organization or individual. We will not provide information that identifies you or your affiliation to anyone
outside the study team, except as required by law.

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Note: The above language is provided by the Office of Management and Budget’s Statistical and Science
Policy office for studies where there was no real statutory basis for the agency to protect the confidentiality
of respondents—This doesn’t mean that the agency would not resist providing identifiable information and
would seek to provide aggregate nonidentifiable information that would help serve whatever purpose the
information was requested for; however, the agency could be legally compelled to provide identifiable
information. This statement is not intended to replace any required Privacy Act statements.

Privacy Act Statement/Privacy Notice Guidance – USE ONLY IF APPLICABLE (Consult with the
Bureau’s Privacy Office)
Privacy Act Statement/Notice should be made available at the time of collection. If the collection is during
a phone interview, inform the individual that a Privacy Act Statement is available upon request, provide a
CFPB email address, and/or refer the individual to a Privacy Act Statement available online.
If a Privacy Act Statement is required, the Privacy Act Statement must include:





Authority: Cite statutory or regulatory authority listed in the SORN.
Purpose: Explain the purpose for which the information is collected.
Routine Use: If the information will be disclosed outside the Bureau, cite the Routine Uses
identified in the relevant System of Records Notice.
Mandatory/Voluntary: Explain whether the collection is voluntary or mandatory, and the impacts, if
any, of not providing the information

If the collection is accompanied by a confidentiality statement, use the following language:



“This information is collected in accordance with a confidentiality statement and will [only/not] be
disclosed as outlined in the Routine Uses for the [cite SORN].”
“This information is collected in accordance with a confidentiality statement and will only be
disclosed as outlined in Routine Uses [a, b, c]

Please note that according to 5 CFR 1320.8(b)(3)(v) any pledge of confidentially must be accompanied
with the legal authority for such a pledge.
If a Privacy Notice is required, the Privacy Notice should contain all features of the Privacy Act
Statement, but not cite a SORN.
•
Cite statutory or regulatory authority that permits collection.
•
Explain the purpose for which the information is collected.
•
Explain whether the responses will be kept confidential.
•
Explain how the information will be shared and if information that will be shared
includes direct identifiers or aggregated, anonymous information.
•
Explain if information will be made publicly available and what steps will be taken to
reduce the likelihood that an individual may be re-identified.
•
Explain whether the collection is voluntary or mandatory, and the impacts, if any, of not
providing the information.
Additional considerations include:
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•
•
•

•

If the notice contains a vague purpose statement in order to ensure the validity of the
study, provide more specific notice after the study has concluded. Privacy Office must
approve any exceptions.
If CFPB uses a third party collaboration tool to collect or manage the information
collection and analysis, such as an online survey tool, direct respondents to the Third
Party’s Privacy Policy. See CFPB Third Party Collaboration Tool Guidance.
If compensation is provided to individuals, explain that the identifying information
necessary to effect payment will be kept separately from the survey results and only used
for the purposes of effecting payment.
Provide notice in a language that can be understood by the individual.

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