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

Johnson-O'Malley Student Count
Purpose

The Johnson-O'Malley (JOM) Supplemental Education Program Modernization Act (Public Law No:115-404) was recently
signed into law December 31, 2018. A requirement of the new law is for the Bureau of Indian Education (BIE) to develop and
publish a preliminary report providing the number of eligible Indian students served or potentially served by each eligible
entity, e.g., Tribes, State Departments of Education and public schools. Therefore, BIE will collect JOM student counts from
eligible entities. Information collected will be used for a preliminary report, to inform tribal consultation, and to develop a final
collection instrument during rulemaking. The BIE will use an Excel document to collect the information. The form will be sent
via email and will be made available on the BIE's website. The data collection process will be open for 30-60 days.
This data collection process is a pre-test for the yearly count that BIE will have to conduct after the JOM regulations are
promulgated. The law states that an annual report, including student counts for the JOM program must be published after this
initial data collection and preliminary report. The results of rulemaking may affect the type of data the BIE needs to collect,
thus we are requesting to utilize the current tool during a pilot data collection process. Once regulations are finalized, the BIE
will need to collect information related to the JOM program on an annual basis, so this initial count and collection instrument
are precursors to the final product.

Description of Respondents

Members of Tribes, State Departments of Education, public schools and previously private schools

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: Pretest of 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

MAUREEN LESKY

Maureen Lesky

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

Digitally signed by MAUREEN LESKY
Date: 2019.04.08 11:06:48 -06'00'

FOR USE BY ICC PROGRAM STAFF ONLY
Signature

ASHLEY FRY
DOI Tracking Number
2019-BIA-FT70

Signature

Digitally signed by ASHLEY FRY
Date: 2019.04.08 12:21:11 -04'00'

4/8/2019

Date

4/8/2019
Date

signed by JEFFREY PARRILLO
04/09/2019
JEFFREY PARRILLO Digitally
Date: 2019.04.09 09:16:07 -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

Correctional
Activities
Disaster
Management

(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)

(Select One)
Elementary, Secondary, and Vocational Educ

■ Education

(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

(Select One)

Transportation

(Select One)

(Select One)

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

State, Local, or Tribal Government

Number of Annual
Respondents

Number of
Responses Each

Total Annual
Responses

Participation
Time

Total Burden
Hours

530

1

530

1 hour

530 hrs

Federal Cost: (Consult your Bureau/Office Information Collection Clearance Officer for assistance, if necessary)
The estimated annual cost to the Federal government is $ 10,870.30

, based on: (provide details below)

A GS-12-6 ($41.02 hourly wage) will process each submission. The processing time is 30 minutes or
0.5 hours per submission. 530 responses x 0.5 hrs = 265 hrs. 265 hrs x $41.02 hourly wage =
$10,870.30.

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.

The BIE will contact each current and potential JOM grantee for a response, based on a directory
provided by regional offices.

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].”

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