Generic Clearance Submission - CA Kiosk

Requested Item

U.S. Department of State
Draft

Closed

Number

RITM1798460

State

Closed

Requested By

Jazavac, Benjamin

Stage

Completed

Requested For

Jazavac, Benjamin

Created

10-24-2019 11:23:50

Assigned To

Watkins, Pamela

Assignment Group
Short Description

DS-4183: Request for Approval Under the "Generic Clearance for the Collection of Routine

Notes:
PLEASE UPDATE:

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Notes

Assigned To
Watkins, Pamela
Note: This form is routed to the person listed above and will not
automatically route to your supervisor. If needed, update the individual
listed in the above field for this form to be routed correctly.
Add Users to Watch List - [Provides access to view this request, and
receive email updates]

Instructions
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.
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 termsof 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.
Number of Respondents: Provide an estimate of the number of respondents.

Participation Time: Provide an estimate of the number of respondents.
Burden: Provide the Annual burden hours: Multiply the Number of responses by the participation time, and 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 wheather there
will be interviewers (e.g., for surveys) or facilitators (e.g., for focus groups) used.
Please make sure that all instruments, instructions, and scripts are submitted with the request.

Title of Information Collection
Customer Feedback Kiosk
Purpose
The Department of State, Office of Passport Services is conducting a customer survey for customers who apply for their passport in person at
passport agency
Description of Respondents
Passport applicants who wish to provide feedback about their experience while visiting passport agencies
Type of Collection:
Small Discussion Group
(if other)
Feedback Kiosk Survey
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 (Last, First, MI)
Benjamin Jazavac

Title
Program Analyst



Jazavac, Benjamin certified this section of the form on 10-24-2019.
Signature
Jazavac, Benjamin
Date
10-24-2019
To Assist Review, Please Provide Answers to the Following Questions.
Personally Identifiable Information
Is personally identifiable information (PII) collected?
No
If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974?

If Applicable, has a System of Records Notice been published?
No

Gifts or Payments
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?
No
Burden Hours
ds_4183_burdenhours
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{"field":"number_of_respondents","label":"Number of Respondents","mandatory":false,"type":"number","giveFocus":false,"reference":"","choiceOptions":
[],"refQual":"","cellCSS":"","labelCSS":"","show":"always","imageSrc":"","value":"650000","display":"650000","relatedTable":"","disabled":false},
{"field":"category_of_respondent","label":"Category of Respondent","mandatory":false,"type":"text","giveFocus":false,"reference":"","choiceOptions":
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{"field":"participation_time__minutes_","label":"Participation Time
(Minutes)","mandatory":false,"type":"number","giveFocus":false,"reference":"","choiceOptions":
[],"refQual":"","cellCSS":"","labelCSS":"","show":"always","imageSrc":"","value":".10","display":".10","relatedTable":"","disabled":false},
{"field":"burden_hours","label":"Burden Hours","mandatory":false,"type":"number","giveFocus":false,"reference":"","choiceOptions":
[],"refQual":"","cellCSS":"","labelCSS":"","show":"always","imageSrc":"","value":"1083.33","display":"1083.33","relatedTable":"","disabled":false}]]}]
Totals - Number of Respondents
650000
Totals - Participation Time (Minutes)
.10
Totals - Burden Hours
1083.33
Federal Cost
The estimated annual cost to the Federal government is
$120,000
If You Are Conducting a Focus Group, Survey, or Plan to Employ Statistical Methods, Provide Answers to the Following Questions
The selection of your targeted respondents
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
(if other) Explanation

Will interviewers or facilitators be used?
No

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?
No

Please Make sure that all Instruments, Instructions, and Scripts are Submitted with the Request.

IRMOPSENM Final Task

other

OSDBU Analyst Final Task

other

Archive Flag



More Info 1910
Approval
2nd_1910_Co_Chk
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Requested