NA-2023 - TVs in the A2 Cafeteria

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: Televisions in the A2 Cafeteria Survey
DATE OF REQUEST: 4/10/2018
PURPOSE: To gauge respondent preference on what TV channels should be displayed on each
of the three TVs in the A2 cafeteria.

DESCRIPTION OF RESPONDENTS: Employees (including contractors, volunteers,
interns—i.e. non-federal employees, as well federal employees) stationed at the National
Archives at College Park, Md.

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: Dawn Powers
To assist review, please provide answers to the following question:
Page 1 of 3
NA Form 2023 (09-17)
Required by NARA 108

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

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
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
1,000
2 minutes

(1) Individuals or Households

Burden
33

(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?
Yes. We will filter email addresses to those employees identified as being stationed at the
National Archives at College Park, Md.
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 SurveyMonkey online survey
2. Will interviewers or facilitators be used?
Yes
No
3. Length of Collection: From/To: Collection will be one week in duration after OMB
approval.
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

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