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

Forests, wildfire risk, and watershed health in the Rio Grande river basin
Purpose
The USGS is investigating public values for changes in forest restoration treatments within the upper Rio Grande watershed in New
Mexico and Colorado. The Rio Grande watershed supplies water to half of New Mexico’s population, including Albuquerque, Santa
Fe, and many rural communities, but it also is threatened by the risk of high-severity wildfires. Forest restoration treatments can
reduce the risks from high-severity wildfires, including threats to water security, private property, habitat for fish and wildlife, and air
quality. USGS economists are partnering with an economic researcher with Northern Arizona University to review private citizens'
attitudes, perceptions, and the economic values associated with the different potential benefits of these forest restoration treatments.
This information can inform decisions being made by federal, state, local, and non-governmental organizations about the planning and
implementation of these forest restoration treatments across the landscape. Focus groups of up to 60 private citizens in New Mexico
will be conducted to improve the accuracy and clarity of a proposed future delivery in form of a household survey concurrently being
designed to investigate preferences for forest and wildfire risk management. For all three focus groups, respondents will first review a
printed copy of the forest and wildfire risk questionnaire booklet. Next, respondents will be guided through a semi-structured series of
focus group questions orally to gather feedback on the effectiveness and clarity of the survey instrument. The responses from the
three focus groups will be used to improve and refine the forest and wildfire risk questionnaire being developed for future OMB review.

Description of Respondents
For each of the focus groups, we will invite 156 private residents from the following counties to participate. For the first focus group in
Albuquerque, NM: we will invite 156 residents from Bernalillo County, NM. For the second focus group in Española, NM: we will invite
156 residents from Rio Arriba, Sandoval, Santa Fe, and Taos counties, NM. For the third focus group in Albuquerque, NM: we will
invite 156 Spanish-speaking residents from Bernalillo County, NM. Based on past experience with focus groups, we anticipate 15
people per focus group to agree to participate (but no more than a combined 60 total between the 3 focus groups).

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
signed by JAMES MELDRUM
JAMES MELDRUM Digitally
Date: 2018.11.01 16:55:04 -06'00'

James Meldrum

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

FOR USE BY ICC PROGRAM STAFF ONLY
Signature

JAMES SAYER
DOI Tracking Number
2018-USGS-FT58

Signature

Digitally signed by JAMES SAYER
Date: 2018.11.02 08:36:32 -07'00'

11/1/2018

Date

11/02/2018
Date

signed by JEFFREY PARRILLO
11/02/2018
JEFFREY PARRILLO Digitally
Date: 2018.11.02 14:50:44 -04'00'

Page 1 of 4

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:
We will provide respondents who agree to participate one $80 debit card (with PIN) to offset the focus group time burden. Past
experience in similar household studies conducted by economists at Northern Arizona University and other institutions reveal that the
use of a small monetary incentive helps to increase participation over a wide range of population demographics and thus decreases
Federal
Enterprise
Architecture
(FEA) Business
Reference
Model
one “Line
of Business”
and one “Subfunction.”
equity
concerns
in survey
design. Further,
we anticipate
the focus
group(Check
to take only
2-hours,
and thus
is a non-negligible
amount of time
Refer
OMB guidance
“FEA Consolidated
Reference
Model
Version
for
the to
respondent's
participation.
The small mount
on the
debitDocument
card will offset
the2.3”)
burden to the respondent.
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

Water Resource Management

Transportation

(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

60

1

60

2 hours

120 hours

Federal Cost: (Consult your Bureau/Office Information Collection Clearance Officer for assistance, if necessary)
The estimated annual cost to the Federal government is $ 15,000.00

, based on: (provide details below)

Through this cooperative agreement, Northern Arizona University has elected to sub-contract the three focus groups to the Wyoming
Survey and Analysis Center at the University of Wyoming. Past experience has shown an approximation for conducting a focus group
is $5,000 per meeting. Thus, the total estimate through this sub-contract is expected to be $15,000. No other costs to the Federal
Government are anticipated.

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.”
Page 2 of 4

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.

Participants will be identified using the "Reference USA" U.S. white pages database access through the local Poudre River Public
Library in Fort Collins, CO. For each focus group, 6 respondents will be randomly selected for each letter of the alphabet using the
first letter of last names among all residents in the respective combined county regions. A letter will be mailed to each of the 156
selected potential participants explaining the focus group goals, process, and location, and inviting them to respond yes/no to the
invitation via email or telephone. Each focus group will be caped at a maximum of 20 participants each for a maximum total of 60
participants.

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.

Page 3 of 4

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].”

Page 4 of 4