IC Submission Template

REQUEST FOR APPROVAL UNDER THE “GENERIC INFORMATION
COLLECTION PLAN FOR THEOFFICE OF INTERGOVERNMENTAL AFFAIRS
OUTREACH ACTIVITIES”
(OMB CONTROL NUMBER: 3170-0041)
1. TITLE OF INFORMATION COLLECTION:

2. PURPOSE:

3. DESCRIPTION OF RESPONDENTS:
[ ] State Officials & Attorneys

[ ] Local & Tribal Officials

[ ] Local & Tribal Attorneys

[ ] Other (Describe below):

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

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

[ ] In-Person Meeting
[ ] Interview
[ ] Focus Group
[ ] Social Media Poll
[ ] Other: _______________

[ ] Qualitative Survey
[ ] Small Discussion Group
[ ] Online Discussion Forum
[ ] Data Sharing

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

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
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how you will select them?
6. PERSONALLY IDENTIFIABLE INFORMATION:
a. Is personally identifiable information (PII) collected or other information that are
subject to the Privacy Act of 1974? [ ] Yes [ ] No [ ] Not Applicable
b. If applicable, what is the link to the Privacy Impact Assessment (PIA)?

c. Has a System or Records Notice (SORN) been published?
[ ] Yes [ ] No [ ] Not Applicable.
If Yes, provide Federal Register citation for the SORN __ FR ______

7. BURDEN ESTIMATES:
Information Collection

Number of
Respondents

Frequency
(Responses
per
Respondent)

Number of
Annual
Responses

Response
Time
(hours)

Burden
Hours

[Insert rows as needed]
Totals

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

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

8. FEDERAL COST: The estimated annual cost to the Federal government is

$

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9. CERTIFICATIONS:
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) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It uses plain, coherent, and unambiguous terminology that is understandable to
respondents;
(d) 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;
(h) It uses effective and efficient statistical survey methodology; and
(i) It makes appropriate use of information technology.

CERTIFICATION FOR INFORMATION COLLECTIONS SUBMITTED UNDER A
GENERIC INFORMATION COLLECTION PLAN
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By submitting this document, the Bureau certifies the following to be true:
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.
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.
The data collection is not statistically significant, the sample is not intended to be
representative, and the results will not be used to make inferences beyond the survey
sample.
The results will not be used to measure regulatory compliance or for program
evaluation.

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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. Comment card for soliciting feedback on xxxx)

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.

7.

BURDEN ESTIMATES:
Information Collection: 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.
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.)
Average Response 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 in hours.
Burden Hours: 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.

8.

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.

9.

CERTIFICATION: 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 WITH THE REQUEST

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 3170-0041. It
expires on XX/XX/20XX. The time required to complete this information collection is estimated to average approximately [## minutes /

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hours] per response, including the time for reviewing any instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. 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. 3170-0041
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
[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]

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.

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