IC Submission Template

CONSUMER FINANCIAL PROTECTION BUREAU
REQUEST FOR APPROVAL UNDER THE GENERIC CLEARANCE
FOR CONSUMER COMPLAINT AND INFORMATION COLLECTION SYSTEM
(TESTING AND FEEDBACK)
(OMB Control Number: 3170-0042)

1. TITLE OF INFORMATION COLLECTION:

2. PURPOSE:

3. DESCRIPTION OF RESPONDENTS:

4. TYPE OF COLLECTION: (Check all that apply)
[ ] Customer Satisfaction Survey [ ] Piloting Revisions to Consumer Complaint Form
[ ] Focus group
[ ] Usability or laboratory test (not in live system)
[ ] Web-based
[ ] Other (describe) ___________________
5. PERSONALLY IDENTIFIABLE INFORMATION:
a. Is personally identifiable information (PII) collected? [ ] Yes [ ] No
b. If Yes, is the information that will be collected included in records that are subject
to the Privacy Act of 1974? [ ] Yes [ ] No [ ] Not Applicable
If applicable, what is the link to the Privacy Impact Assessment (PIA)?

c. If Applicable, has a System or Records Notice (SORN) been published?
[ ] Yes [ ] No [ ] Not Applicable
If Yes, provide Federal Register citation for the SORN __ FR ______.

6. GIFTS OR PAYMENTS:

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7. BURDEN HOURS:
Collection of Information

Number of
Respondents

Frequency

Number of
Annual
Responses

Response
Time
(hours)

Burden
Hours

[Insert rows as needed]
Totals

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8. FEDERAL COST: The estimated annual cost to the Federal government is $ ____________
9. DURATION OF TEST:

10. CERTIFICATION:
CERTIFICATION PURSUANT TO 5 CFR 1320.9, AND THE RELATED PROVISIONS
OF 5 CFR 1320.8(b)(3) :
By submitting this document, the Bureau certifies the following to be true:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It uses plain, coherent, and unambiguous terminology that is understandable to
respondents;
(d) Its implementation will be consistent and compatible with current reporting and
recordkeeping practices;
(e) It indicates the retention period for recordkeeping requirements; (not applicable)
(f) It informs respondents of the information called for under 5 CFR 1320.8(b)(3):
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(g) It was developed by an office that has planned and allocated resources for the efficient
and effective management and use of the information to be collected;
(h) It uses effective and efficient statistical survey methodology (not applicable); and
(i) It makes appropriate use of information technology.

CERTIFICATION FOR INFORMATION COLLECTIONS SUBMITTED UNDER A
GENERIC INFORMATION COLLECTION PLAN

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By submitting this document, the Bureau certifies 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.
The data collection is not statistically significant, the sample is not intended to be
representative, and the results will not be used to make inferences beyond the survey
sample.
The results will not be used to measure regulatory compliance or for program
evaluation.

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Instructions
1. 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)
2. 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.
3. 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.
4. TYPE OF COLLECTION: Check all that apply. If you are requesting approval of other
instruments under the generic, you must complete a form for each instrument.
5. PERSONALLY IDENTIFIABLE INFORMATION: Provide answers to the questions.
Any request that includes collecting information about individuals must be reviewed by the
CFPB Privacy office prior to submission to OMB.
6. GIFTS OR PAYMENTS: If you answer yes to the question, please describe the incentive
and provide a justification for the amount.
7. BURDEN HOURS:
Information Collection: List the collection of information occurring under this request (e.g.,
screener, survey, phone survey, web survey, training materials evaluation, conference feedback
etc).
Number of Respondents: List the number of respondents for each information collection.
Frequency. List how many times each respondent will be asked to respond to each information
collection.
Number of Responses: Multiply the number of respondents by frequency. Please round to the
nearest whole hour.
Response 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). Express in hours.
Burden Hours: Provide the Annual burden hours: Multiply the Number of responses and the
participation time. This estimate should be expressed as hours. Please round to the nearest whole
hour.
8. FEDERAL COST: Provide an estimate of the annual cost to the Federal government.
9. DURATION OF TEST: Specify for how long and/or for how many response the test
questions will be conducted (e.g., 3,000 responses and not to exceed 60 days).
10. CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the
collection will be returned as improperly submitted or it will be disapproved.

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Please make sure that all instruments, instructions, and scripts are submitted with the
request; including, as applicable, a list of questions to be tested.

Template Paperwork Act Statement (to be placed on collection instrument(s) either
at the bottom of the first or last page)
Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to
a collection of information unless it displays a valid OMB control number. The OMB control number for this collection is 3170-0042.
It expires on XX/XX/XXXX. The time required to complete this information collection is estimated to average approximately [##
minutes / hours] per response. Responding to this collection of information is voluntary. Comments regarding this collection of
information, including the estimated response time, suggestions for improving the usefulness of the information, or suggestions for
reducing the burden to respond to this collection should be submitted to Bureau at the Consumer Financial Protection Bureau
(Attention: PRA Office), 1700 G Street NW, Washington, DC 20552, or by email to [email protected].

Paper Forms: The information is included either on the form, questionnaire, as part of the instructions, or
in a cover letter or memorandum that accompanies the collection of information. The following should
appear at the top right corner of all paper forms and surveys.
OMB No. 3170-0042
Expiration Date:XX/XX/XXXX
Electronic Forms: The information is included either in the instructions, near the title of electronic collection
instrument, or for on-line applications, on the first screen viewed by the respondent. This information can also be
provided in a separate window with a link titled, “Paperwork Reduction Act Statement”.
Sample Privacy/Confidentiality Statements – USE ONLY IF APPLICABLE
[Standard CFPB Statement]
The Bureau will not disclose any personally identifiable information collected except to the extent that it is required to do so by
law and as provided in the Privacy Act Statement listed below. Additionally, the Bureau will treat the information collected
consistent with its confidentiality regulations at 12 C.F.R. Part 1070, et seq.
[Sample statement for when there is no legal authority for a pledge of confidentiality]
Privacy: Responses to this data collection will be used only for statistical purposes. The reports prepared for this study will summarize findings
across the sample and will not associate responses with a specific organization or individual. We will not provide information that identifies you
or your affiliation to anyone outside the study team, except as required by law.

Note: The above language is provided by the Office of Management and Budget’s Statistical and Science Policy office for
studies where there was no real statutory basis for the agency to protect the confidentiality of respondents—This doesn’t mean
that the agency would not resist providing identifiable information and would seek to provide aggregate nonidentifiable
information that would help serve whatever purpose the information was requested for; however, the agency could be legally
compelled to provide identifiable information. This statement is not intended to replace any required Privacy Act statements.

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