Template for Generic Clearance Submission for Survey

Request for Approval under the

“Generic Clearance for the Collection of Routine Customer Feedback”

OMB Control Number: 1212-0066 (expires 10/31/2017)

TITLE OF INFORMATION COLLECTION: Survey of Benefit Determination Letter and Statement.

PURPOSE:

To help PBGC improve its communications to customers by making documents clearer and easier to understand. PBGC has revised the benefit determination letter and statement that is sent to participants. To assess the clarity of the revision, participants who received the revised letter and statement, and for whom PBGC has valid emails, will be surveyed. If the survey indicates the revised letter and statement are clear and understandable, they will be used more broadly by PBGC in the future.

DESCRIPTION OF RESPONDENTS: Deferred vested participants in the LR Nelson Plan (all of whom received revised benefit determination letters and statements) for whom PBGC had valid emails.

TYPE OF COLLECTIONS:

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

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

[ ] Focus Group [X] Other: email survey

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 completed PBGC benefit applications.

Name: Daniel S. Liebman

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

Personally Identifiable Information:

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

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [X] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Deferred Vested Participants in the LR Nelson Plan who received the revised benefit determination letter and statement and for whom PBGC had valid emails	39	5 minutes	3.25 hours
Totals	39	5 minutes	3.25 hours

FEDERAL COST: Because all the work will be performed by PBGC staff, the annual cost to the government is estimated to be $0.

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

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 [X] 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.

PBGC will collect the names and email addresses of all deferred vested participants in the LR Nelson Plan who received the revised benefit determination letter and statement when their plan terminated. From this population of approximately 180 deferred vested participants, PBGC identified all those with valid emails (39 in total). The thirty-nine will be contacted by email, and asked to complete a survey of their understanding of the letter and determination statement they received.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[X] Other, Explain

PBGC will administer the survey to 39 deferred vested participants who will be contacted by email.

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

Please make sure that all instruments, instructions, and scripts are submitted with the request.