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:

Small, Rural School Achievement Application Customer Feedback Survey

PURPOSE:

The U.S. Department of Education (Department) administers the Small, Rural School Achievement (SRSA) Application for eligible Local Education Agencies (LEAs) to apply for a supplementary formula grant. For the Fiscal Year 2020, the Department implemented a new streamlined application process for the SRSA program. The SRSA Customer Feedback Survey will collect feedback from LEAs who participated in the FY 2020 application. LEA feedback is used by the program office to make informed decisions regarding how to most effectively administer future application rounds. Responses are collected electronically via OMB MAX Survey.

DESCRIPTION OF RESPONDENTS:

This information collection has the potential to interact with 4,500 LEA representatives who accessed the Small, Rural School Achievement Application for the FY 2020.

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:________________________________________________

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
Local educational agencies	4,500 per year	10 minutes	750 hours per year
Totals	4,500 per year	10 minutes	750 hours per year

FEDERAL COST: The estimated annual cost to the Federal government is $375.

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 universe of potential respondents includes all local educational agencies who accessed the SRSA application for the FY 2020. The customer list is comprised of the authorized representatives provided by local educational agencies in the original SRSA application.

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

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

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

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

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