G256 eMod Text Pilot Program Questionnaire

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0651-0080)

TITLE OF INFORMATION COLLECTION: G256: eMod Text Pilot Program Questionnaire

PURPOSE: Gather feedback from the eMod Text Pilot Program participants about overall experience with the Program.

DESCRIPTION OF RESPONDENTS: Only eMod Text Pilot Program participants will be invited to provide feedback about their experience within the Program

TYPE OF COLLECTION: (Check one or multiple)

[ ] Customer Comment Card/Complaint Form [x] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus 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.

Business Unit: _________/Lisa Tran/_ _______________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [x] No

1a. If Yes, is the information that will be collected included in records that are subject to

the Privacy Act of 1974? [ ] Yes [ ] No

2. If applicable, has a System of Records Notice been published? [ ] Yes [x] 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
Questionnaire	100	6 minutes	10 hours
Totals	100	- - -	10 hours

The USPTO estimates that 100% of the questionnaires will be conducted electronically.

FEDERAL COST: The estimated annual cost to the Federal government is the hourly rate of $38.20 per hour for a GS-12 step 1 + 11.46 (30%) * 2 hours (=$99.32) and $59.04 per hour for a GS-14 step 4 + 17.71 (30%) * 3 hours (=$230.25), for a total of $329.57.

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?

124 Customers are in the eMod Text Pilot Program. We anticipate around 20 – 70% survey participation.

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: live poll software

2. Will interviewers or facilitators be used? [ ] Yes [X] No

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