CERTIFICATION:
I certify 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.
Name:
To assist review, please
provide answers to the following question:
Personally Identifiable
Information:
Is
personally identifiable information (PII) collected?
Yes No
If
“Yes”, will any information that is collected be
included in records that are subject to the Privacy Act of 1974?
Yes No
If
“Yes”, has an up-to-date System of Records Notice
(SORN) been published?
Yes
No
Gifts
or Payments:
Is an incentive (e.g. money
or reimbursement of expenses, token of appreciation) provided to
participants?
Yes No
BURDEN HOURS
Category of Respondents:
Individuals or Households
Private Sector
State, Local, or Tribal Governments
Federal Government
Category of Respondent
|
No. of Respondents
|
Participation Time
|
Burden
|
Companies, Other
Stakeholders From the Above Categories
|
300
|
5 min (0.083 hours)
|
25 hours
|
FEDERAL COST: The
estimated annual cost
to the Federal government is
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 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?
Administration of the
Instrument
How
will you collect the information? (Check all that apply)
Web-based or other forms of Social Media
Telephone
In-person
Mail
Other (Explain)
Will
interviewers or facilitators be used?
Yes No
Please make sure that all
instruments, instructions, and scripts are submitted with the
request.
Instructions for completing
Request for Approval under the “Generic Clearance for the
Collection of Routine Customer Feedback”
TITLE OF INFORMATION
COLLECTION: Provide the name of the collection that is the
subject of the request.
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.
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.
TYPE OF COLLECTION:
Check one box. If you are requesting approval of other instruments
under the generic, you must complete a form for each instrument.
CERTIFICATION: Please
read the certification carefully. If you incorrectly certify, the
collection will be returned as improperly submitted or it will be
disapproved.
Personally Identifiable
Information: Provide answers to the questions. Note: Agencies
should only collect PII to the extent necessary, and they should
only retain PII for the period of time that is necessary to achieve
a specific objective.
Gifts
or Payments: If you answer yes to the question, please describe
the incentive and provide a justification for the amount.
BURDEN HOURS:
Category of Respondents:
Identify who you expect the respondents to be in terms of the
following categories: (1) Individuals or Households; (2) Private
Sector; (3) State, local, or tribal governments; or (4) Federal
Government. Only one type of respondent can be selected per row.
No. of Respondents:
Provide an estimate of the Number of Respondents.
Participation Time:
Provide an estimate of the amount of time (in minutes) required
for a respondent to participate (e.g. fill out a survey or
participate in a focus group)
Burden: Provide the
Annual burden hours: Multiply the Number of Respondents and the
Participation Time then divide by 60.
FEDERAL COST: Provide
an estimate of the annual cost to the Federal government.
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. Please provide a description of how you
plan to identify your potential group of respondents and how you
will select them. If the answer is yes, to the first question, you
may provide the sampling plan in an attachment.
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.
Submit all instruments,
instructions, and scripts are submitted with the request.