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

Pilot Test of Web-based Application for the National Park Service U.S. Civil Rights Network (USCRN)
Purpose
The African American Civil Rights Network Act of 2017 authorized the Department of the Interior to establish within the National Park Service (NPS) a
U.S. Civil Rights Network (USCRN or Network) responsible for coordinating and facilitating Federal and non-Federal activities to commemorate, honor,
and interpret the history of the African American civil rights movement. These activities include:
(1) all NPS units and programs that relate to the African American civil rights movement from 1939 through 1968;
(2) other properties that relate or have a verifiable connection and that are included in, or eligible for, the National Register of Historic Places; and
(3) other facilities and programs (governmental and nongovernmental) that are directly related to the movement.
Sites, facilities, programs or properties applying for inclusion in the Network must complete and submit the USCRN application. The NPS will use the
application to determine eligibility based upon clear, convincing, and well-documented evidence of historical association to the African American civil
rights movement.
The purpose of this request is for approval to pilot test an electronic fillable-fileable USCRN application form. Unlike the NPS National Historic
Landmarks program that uses a fillable but not fileable form that is submitted by email or mail, USCRN applicants will use an on-line process to
nominate properties and programs. This is allow faster completion and processing times making submissions available in real-time allowing different
administrators of the program direct access as needed. Fillable-fileable forms also reduces the time needed to fill out by allowing respondents to select
pre-populated answers that will eliminate guesswork and improve the accuracy and readability of responses.
We will use the results of the pilot test to determine the form’s usability and to determine the best ways to promote the new application process.
Ultimately, we would like 100% of the applicants submit nominations using this the fillable-fileable format.

Description of Respondents

Per the African American Civil Rights Network Act of 2017 (PL 115-104) participants in this process will include, but are not limited to
Federal, State and local agency personnel, non-government agencies, private entities, and members of the general public.

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

Customer Satisfaction Survey

Usability Testing (e.g., Website or Software

Small Discussion Group

Focus Group
■

Other: Pilot test of Web-based form

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

JOY BEASLEY

Joy Beasley

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

Digitally signed by JOY BEASLEY
Date: 2018.10.31 15:50:26 -04'00'

FOR USE BY ICC PROGRAM STAFF ONLY
Signature

PHADREA PONDS
DOI Tracking Number
2018-NPS-FT55

Signature

Digitally signed by PHADREA PONDS
Date: 2018.10.30 14:40:00 -06'00'

10/31/2018

Date

10/30/2018
Date

signed by JEFFREY PARRILLO
11/01/2018
JEFFREY PARRILLO Digitally
Date: 2018.11.01 07:39:09 -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

Central Files--Interior, NPS-10 (October 28, 2008)

73 FR 63992

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)

(Select One)

(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)

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 Management

Transportation

(Select One)

Workforce
(Select
Management
Burden Hour Calculation
Category of Respondent

State, Local, or Tribal Government

(Select One)

One)
Number of Annual
Respondents

Number of
Responses Each

Total Annual
Responses

Participation
Time

Total Burden
Hours

350

1

350

30 mins

175 hours

Federal Cost: (Consult your Bureau/Office Information Collection Clearance Officer for assistance, if necessary)
The estimated annual cost to the Federal government is $ 12,018.00

, based on: (provide details below)

This amount represents total estimated time per year (in hours) of the current salary and benefits of Network staff to:
1) consultations, (2) processing applications, and (3) reviewing requests.
Supervisory Historian (GS-14/5), 20 hours x $102.50 = $2,050
Program Coordinator (GS-12/5), 30 hours x $70.85 = $2,125
Cultural Resources Tech (GS-9/5), 30 hours x $48.86 = $1,466
Historian/Reviewer (x3) (GS-12/5), 30 hours x $70.85 = $2,125 x 3 = $6,377
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.

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

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

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)
Purpose: Provide a brief description and how you will use this information collection. 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, OMB will return the collection as improperly submitted or
they will disapprove your request.
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 Hour Calculation:
•
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. You may select only
one category.
•
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 in minutes 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:
Selection of 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 you will collect the information. 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.
Submission of the Survey Instrument, Instructions and Scripts: You must submit a copy of the survey instrument, including all
associated instructions and scripts. The survey instrument document must show the OMB Control Number 1090-0011 and Expiration
Date 08/31/2018, along with the following Statements:
Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act
(44 U.S.C. 3501) to [insert brief justification for collection of information]. Your response is voluntary and we will not
share the results publicly. We may not conduct or sponsor and you are not required to respond to a collection of
information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey
and assigned OMB Control Number 1090-0011, which expires ##/##/####.
Estimated Burden Statement: We estimate the survey will take you ## minutes to complete, including time to read
instructions, gather information, and complete and submit the survey. You may submit comments on any aspect of
this information collection to the Information Collection Clearance Officer, [Insert Bureau], [Insert mailing address].”

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