National State Planning and Research (SPR) Forum

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

TITLE OF INFORMATION COLLECTION: Survey for SPR-B Forum Feedback

PURPOSE:

The purpose of this survey is to request feedback from participants after the Federal Highway Administration (FHWA) hosted a National State Planning and Research (SPR) Forum. The survey will seek feedback on the success of the Forum, chosen topic areas and action items suggested from participants. The results of this survey will be used to improve future virtual SPR forums.

DESCRIPTION OF RESPONDENTS:

The respondents will include State Department of Transportation (DOT) employees and FHWA Staff.

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: ______________________

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:_Tricia Sergeson_______________________________________________

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 [ ] No N/A

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

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 Government	90	10 minutes	15
Federal Government	50	10 minutes	8.33
Totals	140	20 minutes	23.33

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?

We plan to administer the survey to both FHWA Staff and State DOT participants that attended the SPR-B Forum. The survey is a short 10 question survey that will be used to garner feedback from their experience attending the forum.

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

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

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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