HRSA Stakeholder Satisfaction Survey

Theresa Spriggs

9/18/2018

(Rev. 09/2018)
U.S. Department of the Interior

0MB Control. No. 1090-0007

Expiration Date ##/##/####

TO ASSIST REVIEW, PLEASE PROVIDE ANSWERS TO THE FOLLOWING QUESTIONS:
Personally Identifia ble Information (Please consult with your Bureau/Office Privacy Act Officer)
1. Will you collect any personally identifiable information (see 0MB Circular No. A-130 for an explanation of this term)?
� No D 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 D Yes
3. If applicable, has a System or Records Notice (SORN) been published?
No D Yes If "Yes," please provide the title and FR citation below:
FR Citation for SORN
Title of SORN:

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Gifts or Pa yments (Please refer to 0MB guidance "Questions and Answers When Designing Survfi.'i.S for Information Col/ectionsj
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? ijJ No D 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 0MB Quidance "FEA Consolidated Reference Model Document Version 2.3")
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Line of Business

Community and
Social Services
Defense and
National Security
Economic
Development

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Energy

Co"ectional
□ Activities

(Select One)

LJ Disaster

(Select One)

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(Select One)
(Select One)

General Science
and Innovation
Homeland Security
Intelligence
Operations

(Select One)

Law Enforcement

(Select One)

Natural Resources
Workforce
Management

(Select One)

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Line of Business

Subfunction

(Select One)

Subfunction
(Select One)
(Select One)

Management

Education

(Select One)

LJ Environmental
Management

(Select One)

Health

(Select One)

Income Security
International Affairs
and Commerce
Litigation and
Judicial Activities
Transportation

(Select One)

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(Select One)

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(Select One)
(Select One)
(Select One)

(Select One)

Burden Hour Calculation

Category of Respondent
State, Local, or Tribal Government

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Number of Annual
Resoondents
450

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Number of
Resoonses Each
1

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Total Annual
Resoonses
450

Participation

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Time

15 minutes

Federal Cost: (Consult your Bureau/Office Information Collection Clearance Officer for assistance, if necessary)
The estimated annual cost to the Federal government is $ 64,166.00

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Total Burden
Hours
112.5

, based on: (provide details below)

Cost of the survey: $64,166.00

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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