na-2023_Remembering_Vietnam

OMB Control No.: 3095-0070
Expiration date: 12-31-2020

Request for Approval under the
“Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”
(OMB Control Number: 3095-0070)
TITLE OF INFORMATION COLLECTION: Remembering Vietnam
Visitor Input Station
DATE OF REQUEST: 3/6/2018
PURPOSE: The Vietnam War had a profound effect on people who experienced it. Those
who were born after the war may have older relatives whose lives were changed by it. The
Visitor Input station allows visitors to use iPads to share their thoughts, personal
experiences, feelings, and recollections about the war and to contribute to a conversation
stimulated by the exhibit.
DESCRIPTION OF RESPONDENTS: Public visitors to the "Remembering Vietnam"
exhibition.
TYPE OF COLLECTION: (Check one)
Customer Comment Card/Complaint Form
Usability Testing (e.g., Website or Software)
Focus Group

Customer Satisfaction Survey
Small Discussion 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: Michael Hussey
To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected?
Yes
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

Page 1 of 3
NA Form 2023 (09-17)
Required by NARA 108

OMB Control No.: 3095-0070
Expiration date: 12-31-2020

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 Respondent

No. of
Participation
Respondents Time
10,000
2 minutes

(1) Individuals or Households

Burden
333

(3) State, local, or tribal governments
Totals
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?
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
1. How will you collect the information? (Check all that apply)
Web-based or other forms of Social Media (if applicable, please add url)
Telephone
In-person
Mail
Other, Explain Information will be collected through an online surveying utility--i.e.
online survey link which can be accessed by all visitors.
2. Will interviewers or facilitators be used?
3.

Yes

No

Length of Collection: From: 3/14/2018 To: 1/6/2019

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

Page 2 of 3
NA Form 2023 (09-17)
Required by NARA 108

OMB Control No.: 3095-0070
Expiration date: 12-31-2020

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)
DATE OF REQUEST: Enter the date the request is made.
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.
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. Enter the date span “from” and “to” that this survey
will be administered.
Submit all instruments, instructions, and scripts with the request.

Page 3 of 3
NA Form 2023 (09-17)
Required by NARA 108