ICR Submission Template

REQUEST FOR APPROVAL UNDER THE “GENERIC CLEARANCE FOR
DEVELOPMENT AND OR TESTING OF MODEL FORMS,
DISCLOSURES, TOOLS, AND OTHER SIMILAR RELATED
MATERIALS” (OMB CONTROL NUMBER: 3170-0022)
1. TITLE OF INFORMATION COLLECTION:

2. PURPOSE:

3. DESCRIPTION OF RESPONDENTS:

4. TYPE OF COLLECTION (ADMINISTRATION OF THE INSTRUMENT):
a.

How will you collect the information? (Check all that apply)
[
[
[
[

] Web-based or other forms of Social Media
] In-person
] Small Discussion Group
] Other, Explain ______________________

[ ] Telephone
[ ] Mail
[ ] Focus Group

b. Will interviewers or facilitators be used?
[ ] Yes [ ] No [ ] Not Applicable
c.

What type of disclosure or model form is being tested?
[
[
[
[

] Mortgage
] Credit Card
] Remittances
] Payday Loans

[
[
[
[

] Student Loan
[ ] Electronic Disclosure
] Pre-paid Cards
[ ] Check Cashing
] Debt Collection [ ] Checking Accounts
] Other (Explain): ___________________

5. FOCUS GROUP OR SURVEY:
If you plan to conduct a focus group or survey, please provide answers to the following
questions:
a. 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 [ ] No [ ] Not Applicable

b. If the answer is yes, please provide a description below. 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?

6. PERSONALLY IDENTIFIABLE INFORMATION:
a. Is personally identifiable information (PII) collected? [ ] Yes [ ] No
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
If applicable, provide link to the Privacy Impact Assessment (PIA):

c. If Applicable, has a System or Records Notice been published?
[ ] Yes [ ] No [ ] Not Applicable
If yes, cite the SORN.
Title:___________________________________
___ FR _______________.

7. INCENTIVES:
a. Is an incentive provided to participants? [ ] Yes [ ] No
b. If Yes, provide the amount or value of the incentive? $___________.
c. If Yes, provide a statement justifying the use and amount of the incentive.

8. BURDEN ESTIMATES:
Information Collection

Number of
Respondents

Frequency

1x
[Insert rows as needed]
1x
/////////////////////
//////////////////
Totals

Number of Annual
Responses

Average
Response
time
(hours)

Burden
Hours

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

9. FEDERAL COST: The estimated annual cost to the Federal government is $_________.

10. CERTIFICATIONS
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)

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;
(e) It indicates the retention period for recordkeeping requirements;
(f) 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;
(g) 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) It uses effective and efficient statistical survey methodology; and
(ii) It makes appropriate use of information technology.

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

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 results are not intended to be disseminated to the public.
Information gathered will not be used for the purpose of substantially informing influential policy
decisions.
(f) The collection is targeted to the solicitation of opinions from respondents who have experience
with the topics or issues being studied.
(g) The results will not be used to measure regulatory compliance or for program evaluation.
(h) The results are not intended to be generalizable or otherwise draw inferences beyond the surveyed
population.

Instructions

(will be deleted prior to submission to OMB)
1.

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the
request. (e.g. Focus group to test disclosures for mortgage loan products).

2.

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.

3.

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.

4.

TYPE OF COLLECTION: Check all that apply. If you are 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.

5.

FOCUS GROUPS OR SURVEY: If you are conducting a focus group or survey please provide
answers to the following questions:
a. Identify if you have or will have a list of potential respondents (e.g., conference participants).
b. 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.

6.

PERSONALLY IDENTIFIABLE INFORMATION (PII): Provide answers to the questions.
Also, if PII will be collected, please consult with the Bureau’s Privacy office before submitting
this request to the PRA Team. If applicable, provide a link to the Privacy Impact Assessment
(PIA) and the System of Records Notice (SORN) citation should provide the title and Federal
Register citation.

7.

INCENTIVES: 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-tofind 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.
Original regulations implementing the 1980 PRA allowed incentives only under extraordinary circumstances.
Current regulations require agencies to provide “an explanation for a decision for any payment or gift to
respondents, other than remuneration of contractors or grantees”
(See 5 CFR 1320.5(a)(1)(iii)(D)).
How to Justify Incentives:
•
•
•
•
•
•

Demonstrate need for incentives to improve response rates, validity, and reliability.
Demonstrate higher “out-of-pocket” costs to respondent or unusual, intrusive demands.
Provide data showing impact of incentives on response rates, costs, and survey quality.
Conduct experiments to demonstrate whether incentives work as hypothesized.
Demonstrate the cost effectiveness of the incentive (e.g., compared to failed study or cost to redo the study).
Demonstrate need due to special populations, such as control groups for longitudinal studies. (Note: OMB
does not accept the use of incentives for recruiting poor and/or minority groups nor do they accept incentives
paid to companies.)
• Consider OMB’s “rule-of-thumb” for incentive amounts (no more than $5 to $10 for upfront cash incentives
for non-in person surveys and $40 to $75 for focus groups).

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8.

BURDEN ESTIMATES:
Category of Respondents: List the individual collections that you are requesting to be approved under this request.
For example, phone survey, web survey, training materials evaluation, conference feedback.
No. of Respondents: Provide an estimate of the Number of respondents.
Frequency: The number of time each respondent will respond to each information collection event.
Number of Annual Responses: Multiply the number of Respondents by the frequency.
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). Express response times in hours.
Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation
time. This estimate should be expressed as hours. Please round to the nearest whole hour.

9.

FEDERAL COST: 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.

10. CERTIFICATIONS: Please read the certification carefully. If you incorrectly certify, the collection
will be returned as improperly submitted or it will be disapproved.
PLEASE MAKE SURE THAT ALL INSTRUMENTS, INSTRUCTIONS, AND SCRIPTS ARE SUBMITTED.

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 3170-0022. It
expires on 11/30/2015. 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. 3170-0022
Expiration Date: 11/30/2015

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 Privacy/Confidentiality Statements – USE ONLY IF APPLICABLE (consult with the Privacy Office)
[Standard CFPB 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 C.F.R. Part 1070, et seq.

[Sample statement for when there is no legal authority for a pledge of confidentiality]

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Privacy: 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.

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.

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