Sample Agency Disclosure Notice, Privacy Act Statement, and Instructions

Sample

Army & Air Force Exchange Service Exchange Retail Sales Transaction Data Customer Satisfactory Survey (Read Agency Disclosure Notice, Privacy Act Statement, and Instructions before completing form.)	OMB NO. 0702- OMB approval expires MMM DD, YYYY
AGENCY DISCLOSURE NOTICE The public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0702-XXXX). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS. Responses should be sent to your local Exchange or to the Army and Air Force Exchange Service Business Development at 3911 S. Walton Walker Blvd., Dallas, TX 75236-1598.
PRIVACY ACT STATEMENT AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 8013, Secretary of the Air Force; 10 U.S.C. 2481, Defense Commissary and Exchange Systems: Existence and Purpose; and Army Regulation 215-8/Air Force Instruction 34-211(I), Army and Air Force Exchange Service Operations; and E.O. 9397 (SSN), as amended. PRINCIPAL PURPOSES(S): This survey collects information which will enable the Exchange to carry out its mission of enhancing the quality of life for authorized patrons as well as obtaining aggregate patron demographic data for use in proving patron shopping satisfaction. ROUTINE USE(S): Your records may be disclosed outside of DoD pursuant to Title 5 U.S.C. §552a(b)(3) regarding DoD “Blanket Routine Uses” published at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. This includes disclosure to contractors for improvement of Exchange programs, to incentive programs, and pursuant to 5 U.S.C. 552a(b)(12) to a consumer reporting agency. In addition, records may be disclosed to Federal agencies, and state, local and territorial governments. DISCLOSURE: Voluntary. The collection of data is triggered solely by the patron’s desire to provide feedback on his/her Exchange shopping experience. Without this feedback, the Exchange would be unable to provide overall customer satisfaction.
INSTRUCTIONS Think about your last shopping experience at an Exchange facility when answering the questions on the survey. Questions are optional. To complete the survey, press the done button.