Pavement Surface Condition Workshop Survey

Fast Track Form Pavement Resiliency Peer Exchanges 2020 (003).docx

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Pavement Surface Condition Workshop Survey

OMB: 2125-0628

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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 2125-0628)

Shape1 TITLE OF INFORMATION COLLECTION: Pavement Surface Condition Workshop Survey


PURPOSE: Conduct customer satisfaction survey to determine interests and participation in proposed Pavement Resiliency Peer Exchanges.









DESCRIPTION OF RESPONDENTS: State DOT employees, Pavement Material Manufacturers, Academia working in Pavement Materials and Design.







TYPE OF COLLECTION: (Check one)


[ ] Customer Comment Card/Complaint Form [X] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [ ] Other: _Email Questionnaire___


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.


Name:____Heather Dylla____________________________________________


To assist review, please provide answers to the following question:


Personally Identifiable Information:

  1. Is personally identifiable information (PII) collected? [ ] Yes [ X] No

  2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ X ] No

  3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No


Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [ X ] No





BURDEN HOURS


Category of Respondent

No. of Respondents

Participation Time

Burden

State DOTs

40

10 minutes

6.66 hrs

Vendors, Consultants

15

10 minutes

2.5 hrs

Totals

55


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FEDERAL COST: The estimated annual cost to the Federal government is $0____________


If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:


The selection of your 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? [ X] Yes [ ] No


If the answer is 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?


List of Contacts at participating DOTs and Industry.

Please view spreadsheet for invitation list to peer exchanges.





Administration of the Instrument

  1. How will you collect the information? (Check all that apply)

[X] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

  1. Will interviewers or facilitators be used? [ ] Yes [ X ] No


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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleDOCUMENTATION FOR THE GENERIC CLEARANCE
Author558022
File Modified0000-00-00
File Created2021-01-13

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