2019 230 DeCA - 1090-0007 Generic Clearance Request Form 6.13.19

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

OMB Control. No. 1090-0007
Expiration Date ##/##/####

REQUEST FOR APPROVAL UNDER THE
“AMERICAN CUSTOMER SATISFACTION INDEX
"CUSTOMER SATISFACTION SURVEYS"”

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

2019 DeCA customer receipt survey
Purpose
To receive feedback from customers in order to improve the commissary experience for customers. DeCA previously completed a
survey with their own Agency clearance Armed Forces General Military law 10 U.S.C. 1782, survey of military families. They are
moving to a more mobile way of collecting the information and focusing it on the customer experience in order to improve customer
satisfaction.
The results of this survey will only be used to improve customer satisfaction with the commissary. The commissary intends to use the
data collected to focus efforts on improving the customer experience while shopping.

Description of Respondents
Customers of the commissary will receive a link to a survey on their cash register receipt. This link can be used via mobile or
computer devices. The link will take them directly to the survey.

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

DOI Tracking Number

Signature

Date

Date

Page 1 of 4

OMB Control. No. 1090-0007
Expiration Date ##/##/####

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

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

(Select One)

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

1440

1

1440

5 min

120

Federal Cost: (Consult your Bureau/Office Information Collection Clearance Officer for assistance, if necessary)
The estimated annual cost to the Federal government is $ 129,000.00

, based on: (provide details below)

All receipts at all commissaries will have the link to the survey. Approximately 80 million shoppers at the commissary each year. With
120 surveys completed per month for previous collections of this type and 5 minutes for each survey there are approximately 120
burden hours for the collection of this information.
In addition, the commissary hired FCG to develop questions in accordance with our OMB survey clearance that would allow them to
improve the experience for their customers. Identifying who their target customers are helps with the collection of information. For
example knowing that a customer has small children can help the commissary place items together that would improve the customer
experience. Thereby improving customer satisfaction.
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

OMB Control. No. 1090-0007
Expiration Date ##/##/####

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

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.

Customers of the commissary are military families. These include active duty, retired, and some authorized civilian employees.

Sample Response to Question 1 Above:
Participants will self-select by choosing to follow the link to submit a response to the survey.
Participants can opt out at any time after starting the survey.
Administration of the Instrument:
2.

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

Telephone

In-person

Mail

Other: Link on the receipt of transaction

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

OMB Control. No. 1090-0007
Expiration Date ##/##/####

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

Instructions for completing Request for Approval under the
“American Customer Satisfaction Index "Customer Satisfaction Surveys"”
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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