SC Survey Generic Submission Template

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 3045-0137)
TITLE OF INFORMATION COLLECTION:
PURPOSE:
We propose to hold discussions (telephone conversations) with former grantee program staff,
CNCS Senior Corps staff (e.g., state personnel, area managers), former grantees’ community
partners and former Senior Corps volunteers about the Senior Corps Foster Grandparent, Senior
Companion, and RSVP grantees that have relinquished their grants in 2017 or 2018. Discussion
topics will include reasons they relinquished the grant, their decision-making process, the role of
the state office, the transition to the new grantee, and the effects on volunteer and the
community. Information from these discussions will be used in drafting an evaluation report to
help Senior Corps leadership better understand the practices, experiences, and impact of this
process. These discussions are part of a larger research effort to create case studies across the
Senior Corps grantee caseload.

DESCRIPTION OF RESPONDENTS:
CNCS Senior Corps staff, former Senior Corps grantee staff, community partners of former
grantees and former volunteers

TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[ ] Customer Satisfaction Survey
[ x] Small Discussion Group
[X ] Other: Interviews

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:

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Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [x ] No
2. If Yes, will any information that is collected be included in records that are subject to the
Privacy Act of 1974? [ ] Yes [ ] No
3. 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? [ x ] Yes [ ] No

BURDEN HOURS
Category of Respondent

No. of
Respondents
4 people x 15
sites
4 people x 15
sites
1 person x 15
sites

Private, non-profit sector—grantee staff
Volunteers
Community Partners

Participation
Time
20 min/person
15 min/person
20 min/person

Totals

Burden
1200
mins
900
mins
300
mins
2400
mins

FEDERAL COST: The estimated annual cost to the Federal government is ___$1,200______
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?
[ ] 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?
Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[ ] Web-based or other forms of Social Media
[ x ] Telephone
[ ] In-person
[ ] Mail
[ ] Other, Explain

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2. Will interviewers or facilitators be used? [ x] 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. (e.g. Comment card for soliciting feedback on xxxx)
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 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 responses and the
participation time and 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.

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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.

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