Request for Approval

DI-4011 (Rev. 07/2018)
U.S. Department of the Interior

OMB Control. No. 1090-0011
Expiration Date 10/31/2021

REQUEST FOR APPROVAL UNDER THE
“DOI GENERIC CLEARANCE FOR THE COLLECTION OF
QUANTITATIVE FEEDBACK ON AGENCY SERVICE DELIVERY”

See Page 4 for Instructions on Completing This Form
Title of Information Collection

Eastern Massachusetts National Wildlife Refuge Complex Hunter Survey
Purpose
The Eastern Massachusetts National Wildlife Refuge Complex would like to survey visitors that participate in our hunt program. We
are hoping to gauge the perspectives and opinions of the hunters regarding the quality of their hunting experience on our refuges, the
responses of which will be used to provide crucial data for informed management and increased hunter satisfaction and participation.
The results of the survey will be used to identify areas of the hunt program where there is strong participation and satisfaction, as well
as identify potential areas for improvement.
The data obtained through this survey will be used to conduct a more accurate assessment of the species and number of wildlife
harvested on the refuges each year. The data collected on harvests may be used to inform the potential for future hunt expansions on
the refuges.

Description of Respondents
Visitors who partake in the hunt program at the Assabet River, Great Meadows, and Oxbow National Wildlife Refuges will be the
individuals surveyed. Each hunter acquires a permit to hunt on our refuges through a 3rd-party vendor (CarVaTech USA). If the
survey is approved, the 3rd-party vendor will distribute an email to the hunters inviting them to participate in the survey, which will be
on the 3rd-party vendor’s webpage. The results of the survey will be used for internal-use only.

Type of Collection (Check One)
Customer Comment Card/Complaint Form

Customer Satisfaction Survey

Focus Group

Usability Testing (e.g., Website or Software

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.
Typed Name of Requester
Signature
Date

Bureau ICCO
Recommend
Not Recommended
DOI PRA Program Lead
Approved
Not Approved

FOR USE BY ICC PROGRAM STAFF ONLY
Signature

MADONNA BAUCUM
DOI Tracking Number
2018-FWS-FT3

Signature

Digitally signed by MADONNA BAUCUM
Date: 2018.10.17 11:07:15 -04'00'

Date

10/17/2018
Date

signed by JEFFREY PARRILLO
10/18/2018
JEFFREY PARRILLO Digitally
Date: 2018.10.18 11:35:59 -04'00'

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DI-4011 (Rev. 07/2018)
U.S. Department of the Interior

OMB Control. No. 1090-0011
Expiration Date 10/31/2021

TO ASSIST REVIEW, PLEASE PROVIDE ANSWERS TO THE FOLLOWING QUESTIONS:
Personally Identifiable Information (Please consult with your Bureau/Office Privacy Act Officer)
1. Will you collect any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)?
No
Yes If “Yes,” please consult with your Bureau/Office Privacy Act Officer.
2. If “Yes”, is the information to be collected included in records that are subject to the Privacy Act of 1974?
No
Yes
3. If applicable, has a System or Records Notice (SORN) been published?
No
Yes If “Yes,” please provide the title and FR citation below:
Title of SORN:
FR Citation for SORN
Gifts or Payments (Please refer to OMB guidance “Questions and Answers When Designing Surveys for Information Collections”)
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?
No
Yes If
“Yes”, please describe the incentive and provide a justification for the amount:

Federal Enterprise Architecture (FEA) Business Reference Model (Check only one “Line of Business” and one “Subfunction.”
Refer to OMB guidance “FEA Consolidated Reference Model Document Version 2.3”)
Line of Business
Subfunction
Line of Business
Subfunction
Community and
Social Services
Defense and
National Security
Economic
Development

(Select One)

Correctional
Activities
Disaster
Management

(Select One)

(Select One)

Education

(Select One)

Energy

(Select One)

Environmental
Management

(Select One)

General Science
and Innovation

(Select One)

Health

(Select One)

Homeland Security

(Select One)

(Select One)

(Select One)

Income Security

(Select One)

Intelligence
Operations

(Select One)

(Select One)

Law Enforcement

(Select One)

International Affairs
and Commerce
Litigation and
Judicial Activities

Natural Resources

Conservation, Marine and Land ManagementTransportation

(Select One)

(Select One)

Workforce
(Select One)
Management
Burden Hour Calculation
Category of Respondent

Individuals/Households

Number of Annual
Respondents

Number of
Responses Each

Total Annual
Responses

Participation
Time

Total Burden
Hours

250

1

250

5 min

21

Federal Cost: (Consult your Bureau/Office Information Collection Clearance Officer for assistance, if necessary)
The estimated annual cost to the Federal government is $ 1,552.52

, based on: (provide details below)

The 3rd-party vendor will provide the approved hunter survey on their website for a one-time start-up cost of no more than $1,500.
Refuge staff will be able to download the collected survey data directly from the 3rd-party vendor’s website for internal analysis.
Internal analysis of the data for presentation to other staff members will be carried out by one GS-9 step 1 staff member and should
not take more than 2 hours of the staff member’s time. Therefore, the anticipated total burden to the refuge is $1,552.52.

Sample Response to Federal Cost Question:
“If we receive 20 submissions and it takes 30 minutes to process and implement each one, then the total burden is $322.40
assuming a GS-7 step 5 is processing the submissions. Please note, however, that this custom form is a tool meant to accept
submissions in a standard format rather than through the freeform submissions that would otherwise come in by personal email.
Thus the existence of this form actually saves the government money by standardizing submissions and decreasing the workload of
processing each one.”
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DI-4011 (Rev. 07/2018)
U.S. Department of the Interior

OMB Control. No. 1090-0011
Expiration Date 10/31/2021

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the
following questions:
Selection of 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?
No
Yes If “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.

All participants in the refuges’ hunt program will receive the online survey through the 3rd-party vendor and the respondents that wish
to participate will submit their answers using the 3rd-party vendor’s website. Participation is completely voluntary.

Sample Response to Question 1 Above:
“Participants will self-select by choosing to follow the link to submit a resource. This is really no different than any website’s “Contact
Us” type of link; this submission form is only used by those who want to contribute to the toolkit. The “Submit a resource” link will be
located on the bottom of the toolkit homepage.”
Administration of the Instrument:
2.

How will you collect the information? (Check all that apply)
Web-based or other forms of Social Media

Telephone

Mail

Other:

In-person

Use of Interviewers or Facilitators:
3. Will you use interviewers or facilitators?
No

Yes
PLEASE SUBMIT SURVEY INSTRUMENT, INSTRUCTIONS, AND SCRIPTS WITH YOUR REQUEST.

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