Generic Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 1880-0542)

TITLE OF INFORMATION COLLECTION: CAPRA Conference Attendee Feedback Survey

PURPOSE: The purpose of this survey is to collect feedback information from conference attendees about the CAPRA PRA conference.

DESCRIPTION OF RESPONDENTS: Respondents to this survey include federal government employees from cabinet level and smaller agencies who have responsibility for managing the information collection review process for their agencies.

TYPE OF COLLECTION: (Check one)

[ ] 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.

Name:__Stephanie Valentine, 202-245-6115_____________________________________

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? [ ] Yes [X ] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals: Federal Government Employees	200	15 minutes	50 hours
Totals	200		50 hours

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

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?

The list of respondents is identified as attendees of the CAPRA Inaugural PRA Conference. The respondents to the survey will also include only those employees who watch the conference online. A survey will be emailed virtual attendees and a paper copy will be given to in person attendees. It is optional for the user to complete the survey.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ X ] In-person

[ ] Mail

[ X ] Other, Explain – via email

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

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