Justification for Submission

DI-4010 (Rev. 07/2018)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 10/31/2021

JUSTIFICATION FOR SUBMISSION UNDER THE
“DOI PROGRAMMATIC CLEARANCE FOR
CUSTOMER SATISFACTION SURVEYS”

See Page 5 for Instructions on Completing This Form
1. Bureau/Office

2. Date Submitted

Bureau of Indian Education, Division of Performance and Accountability

10/18/2018

3. Survey Title
Parent Survey-Special Education

4. Abstract (Not to exceed 150 words)
The Parent Satisfaction Survey – Special Education is for parents of students with disabilities enrolled in Bureau of Indian Education
(BIE) funded schools. The survey is designed to gather information about school interactions with the support of parents to better
meet the educational needs of their students with disabilities. This twenty-five (25) question customer satisfaction survey (Developed
by the National Center for Special Education Accountability Monitoring (NCSEAM) as part of a larger survey) has been statistically
validated as sufficient to meet the required reporting to the Department of Education’s Office of Special Education Programs (OSEP).
The survey referenced in this document will be used to respond to Indicator 8 of the State Performance Plan (SPP) as is required by
the Office of Special Education (OSEP). Individuals with Disabilities Education Act (IDEA,) P.L. 108-446, requires the submission of
specific data as a requisite to the receipt of Federal funding to support services for students with disabilities attending public schools
and Bureau of Indian Education (BIE) schools. Indicator 8 of the SPP addresses parental involvement and requires reporting the
percent of parents who indicate their child’s school facilitated parent involvement, which resulted in improved educational results for
the child. The responses will help guide efforts to improve services and results for children and families.

5. Bureau/Office Point-of-Contact Information
First Name

Last Name

Donald

Griffin

Title

Bureau/Office

Education Program Specialist

Bureau of Indian Education

Mailing Address

City

1011 Indian School Road NW, Suite 332

Albuquerque

Phone

Email
[email protected]

(505)563-5384

■

Work
Cell

Fax
(505)563-5281

6. Principal Investigation (PI) Point-of-Contact Information
First Name
Same as #5

Last Name

Title

Bureau/Office

Mailing Address

City

Phone

Work
Cell

Fax

State
NM

State

Zip Code
87104

Zip Code

Email

Page 1 of 6

DI-4010 (Rev. 07/2018)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 10/31/2021

7. Name of Program or Office Conducting Survey
Division of Performance & Accountability

8. Description of Customers and Services Provided

Customers: Parents of students with disabilities attending Bureau-funded schools.
Services: Special Education/IDEA compliance
9. Survey Dates
(mm/dd/yyyy)

10/31/2018

(mm/dd/yyyy)
10/31/2021

to

10. Type of Information Collection Instrument (Check ALL that Apply)
Intercept

Telephone

Mail

Web-based

Comment Cards

Other: (Explain)
Focus Groups
11. Survey Development (Who assisted in survey content development statistics? Was the survey pretested? How did you
integrate improvements? Which of the six topic areas did you address?)
(Who assisted in survey content development statistics? Was the survey pretested? How were improvements integrated? Which of the six topic areas will be addressed?)
This survey is a part of a larger survey that was developed by the National Center for Special
Education Accountability Monitoring (NCSEAM) between 2002-2005. To develop that larger survey, stakeholder input was obtained from representatives across the nation; the group generated over 500 items that were
submitted to an expert panel. A national validation study of the survey was done during which item responses were obtained in six states (NM, FL, NH, NJ, MS, GA). During the validation process parents of Native American
students were included. NCSEAM maintains an item bank of calibrated items.

12. Survey Methodology (Use as much space as needed; if necessary, include additional explanation on separate page.)
12A. Respondent Universe
All parents, guardians or primary caretakers of students with disabilities
(students with an Individual Education Plan in place) who are attending
BIE schools are potential responders to this survey. Each school will be requested to work with all parents in this category with students attending their school for completion of the survey.

12B. Sampling Plan/Procedure

See next page (2A)
12C. Instrument Administration
The manners of administration will be face-to-face intercept and the BIE’s NASIS secured access internet portal. Each school will be requested to work with the parents of students with disabilities to provide
access to, and completion of, the survey. Interpreters will be available to orally interpret any part or all of the survey in a language the parents understand for both face-to-face and NASIS completed surveys.
This process was used in the development of the survey and analysis showed no response pattern difference between Native American and other minorities and white response patterns.

12D. Expected Response Rate and Confidence Levels

See next page (2A)
12E. Strategies for dealing with potential non-response bias

See next page (2A)
12F. Description of any pre-testing and peer review of the methods and/or instrument (recommended)
BIE-DPA proposes to utilize the NASIS parent portal survey tool and/or paper-copy form for the collection of parent data. BIE school administrative staffs can identify and provide access to parents of students with disabilities that need access to the survey and to NASIS.
Several BIE funded schools and the NASIS program staffs have the ability to, and do on occasion, collect parent input for education program improvement utilizing the NASIS parent portal survey tool. The NASIS parent portal survey tool has been through extensive testing and troubleshooting by
Infinite Campus, the program developer, prior to respondent usage.
The BIE has utilized the NCSEAM paper-copy form of the survey for collection for the past eight years. BIE intends to provide the content from the paper-copy form to the NASIS electronic survey tool.

13. Burden Hours Calculations
Category of Respondent

Number of Annual
Respondents

Number of
Responses Each

Total Annual
Responses

Time per
Response

Total Burden
Hours

Initial Contact

7,000

1

7,000

5 min

583

Completion of Survey Instrument

4,200

1

4,200

15 min

1,050

Totals: 11,200

11,200

1,633

Page 2 of 6

Page 2A - Continuation
12B. Sampling Plan/Procedure
This survey will be a census survey. Opportunities will be provided for all parents of students with disabilities
attending BIE schools to respond to the parent satisfaction survey. The list of individuals to be contacted by the
schools will be generated by school staff employees with approved access to the demographic data for students
with disabilities who have a current IEP utilizing the Native American Student Information System (NASIS), the
BIE secured access internet portal.
The data collection process could involve face-to-face assistance via a school parent liaison and/or electronically
via the NASIS parent portal survey tool for parents who have been granted school level access to their child(s)
NASIS Parent Portal. For parents without access to electronic media, a paper-copy version of the survey will be
provided. Parents may be given the opportunity to respond when they come to the school for any reason, i.e.,
registration, IEP meetings, to check students out of dorms, parent nights, and so forth. For parents not reached
in this manner, home visits will be made.
BIE-DPA will produce a Special Education Parent Survey letter that will provide information to parents about the
survey (explanations for the need of parent program information collection), methods to collect parent survey
(NASIS parent portal and paper-copy), an offering of school and DPA level assistance to parents in completing
the parent survey, due dates for information collection). BIE-DPA will distribute the Special Education Parent
Survey letter to schools for distribution to the homes of all parents of students with disabilities of the school.
12D. Expected Response Rate and Confidence Levels
There are approximately 7,000 students with disabilities (SWD) receiving their education in BIE funded schools at
any given time. It is anticipated that 60% will participate in the survey. Recent collection history using only faceto-face collection has demonstrated the following response rates FY2013: 50.91%, FY2012: 57.43%, and FY
2011: 52.17%. With the face-to-face and electronic (via the NASIS parent portal survey tool) options for parents
to complete the survey, higher response rates than the recent past are expected. This is based on several
factors. Feedback from the schools on the method (electronic submission) and instrument (NASIS) being utilized
to administer the data collection has been positive. Most schools have previously provided access to the NASIS
Parent Portal for all parents with students of the school. This is the means many of the schools utilize to
communicate information to parents: their child’s grade, assignments, school announcements. Some schools are
utilizing the NASIS parent portal survey tool to gather information from parents for school improvement.
12E. Strategies for dealing with potential non-response bias
With face-to-face intercept and internet portal survey models, and the ability to translate for individual parents, a
60% response rate is expected. The face-to-face intercept model will be supported by home visits made by Home
School Liaison personnel at each school. The internet portal survey model can utilize the bulletin board in NASIS
to provide reminders to parents to complete the survey and provide reminders of due dates. Each school will
develop a follow up plan for non-response to keep non-response bias as low as possible.
This is a survey that will include, by individual school, a potential pool of responses ranging from an ‘n’ of one (1)
to an ‘n’ of 160. It is anticipated there will be a varied level of survey completion by school. All responses will be
collated to provide system-wide data for state reporting (OSEP). Limitations to school level reporting will be
identified if data is not reliable due to the ‘n’ size. Individual school reports will not be made if the ‘n’ is too small to
infer valid results or if the ‘n’ is so small as to allow individual student/parent identification.
Demographic information data (age/grade/race/disability), will be suppressed if representation of the group is so
small within the population that it could provide individual student/parent information.

DI-4010 (Rev. 07/2018)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 10/31/2021

14. 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

Social Services

(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)

Workforce
Management
15. Reporting Plan

(Select One)

(Select One)

Data and analysis of that data will be used to report in the BIE APR to OSEP, on a yearly basis. The information will also be provided to each school so they may review the
information with the school community, including parents that participated in the survey. Information will be used to improve parent involvement in the educational
programming for their children with disabilities. Records will be maintained at BIE/DPA. Copies of all reports will be forwarded to the Office of Policy Analysis, upon request.

16. Justification, Purpose, and Use
16A. Survey Justification and Purpose
The survey referenced in this document will be used to respond to Indicator 8 of the State Performance Plan (SPP) as is required by the Office of Special Education (OSEP). PL 108-446 Individuals with Disabilities
Education Act (IDEA) requires the submission of specific data as a requisite to the receipt of federal funding to support services for students with disabilities attending public schools and BIE schools. Indicator 8 of the
SPP addresses parental involvement and requires reporting the percent of parents who indicate their child’s school facilitated parent involvement which resulted in improved educational results for the child.

16B. Survey Goals
The survey goal is to have a parent reported indicator of the percent of parents responding in a manner which indicate that the school involved them in their child’s education planning and this improved results for their
child.

16C. Utility to Managers
The utility to BIE/DPA will be at several levels. At the Central Office level the data gathered will be used a) to report as required on this issue to OSEP, b) to better understand the issue of parent involvement in the schools, parent satisfaction levels,
opportunities for improving services and plan future system-wide activities to address the issue if needed, and c) to understand which Bureau funded schools are doing a good job with the parental involvement issue and which schools would benefit
from technical assistance and support. At the school level a) there will a better understand how the parents of students with disabilities believe their school is involving them in a meaningful way in the educational planning for their child, b) parents will
have been given the opportunity to provide input to the school, and c) the school can address areas identified as a need by the surveys completed at the school. Managers in both instances described above would be the education administrators.

16D. How will the results of the survey be analyzed and used?
See next page (4A)

16E. How will the data be tabulated? How What Statistical Techniques will be used to generalize the results to the entire
customer population? How will limitations on use of data be handled? If the survey results in a lower than anticipated
response rate, how will you address this when reporting the results? (Use as much space as needed; if necessary, include
additional explanation on separate page.)
See next page (4A)

16F. Is this survey intended to measure a Government Performance and Results Act (GPRA) performance measure? If
yes, please include an excerpt from the appropriate document. (Use as much space as needed; if necessary, include additional
explanation on separate page.)
This survey is intended to measure an SPP indicator for reporting to OSEP. See indicator as follows: (The indicator is taken directly from the OSEP SPP guidance.)
State Performance Plan / Annual Performance Report
Indicator 8: Percent of parents with a child receiving special education services who report that schools facilitated parent involvement as a means of improving services and results for children with disabilities. (20 U.S.C. 1416(a)(3)(A))
Measurement: Percent = [(number of respondent parents who report schools facilitated parent involvement as a means of improving services and results for children with disabilities) divided by the (total # of respondent parents of children with disabilities)] times 100.

Page 3 of 6

Page 4A - Continuation
16D. How will the results of the survey be analyzed and used?
The surveys will be completed utilizing the NASIS Parent Portal survey tool or by paper-copy forms. The scoring and
analysis will be conducted by BIE-DPA staff. The survey in question was developed by a national center with an OSEP
provided grant, the purpose of which was to systematically gather a set of data relative to parents of students with
disabilities across the United States. In that development of the survey protocols for analysis were also developed. In
order to maintain consistency and validity of the survey, use of the same process from data gathering to data analysis, is
important.
Use of the NCSEAM instruments to address the parent/family indicators requires the determination of a standard. For
Part B, the standard is defined as the measure at which there is adequate evidence of a schools’ facilitation of parent
involvement.
In July 2005, NCSEAM convened a national group of stakeholders including parents, and state Part B directors,
advocates, service providers, and researchers, to recommend standards for the Part B indicators. Their
recommendations are reported in the NCSEAM Summer Institute Plenary Session presentation.
Procedure
The standard setting process implemented by NCSEAM was a modification of the process described in Stone, G>E>
(2001). Objective Standard Setting (or Truth in Advertising), Journal of Applied Measurement, 2(2), 187-201.
• Convene a workgroup with broad representation of families, state and local agencies, advocates, and other key
stakeholders.
• Distribute a list of all items constituting the scale for which a standard is to be set. The items should be in their
calibration order from lowest (greatest amount of agreement) to highest (lowest amount of agreement). The items will
have been scaled such that the item calibrations represent a combined .95 likelihood of a response across the three
agree categories (agree, strongly agree, very strongly agree).
• Reach consensus as to the highest item with which participants would require an “agree” response in order to
have confidence that the meaning of the indicator (e.g., schools are facilitating parent involvement) is being achieved.
Descriptively, “If families don’t agree with this item” – and, by implication, with all those below it – “then we could not say
that we had acceptable quality in this area.”
• The measure that corresponds to the selected item – or items, when several items are in the same statistical
range - represents the standard.
• Performance on the indicator is calculated as the percent of parents or families with measures at or above the
established standard.
• To take measurement error into consideration, construct a confidence interval around the percent based on the
estimate of measurement error. We will then have 95% confidence that the true percent of parents at or above the
measure is within this % interval.
16E. How will the data be tabulated? How What Statistical Techniques will be used to generalize the results to
the entire customer population? How will limitations on use of data be handled? If the survey results in a lower
than anticipated response rate, how will you address this when reporting the results?
Data will be collected and tabulated electronically for both the NASIS parent portal survey and the paper-copy survey.
BIE-DPA, with the assistance of the IDEA Data Center staff, will conduct the scoring and analysis of the data collection.
Acceptable statistical methodology will be used. Limitations in the data generated by the survey will be addressed in the
analysis. Limitations will be recognized and identified as to the source of the limitations so that planning for subsequent
survey collections can address the limitations in a manner determined by the nature of the limitation. If a single school
has a low response rate BIE will request the school to do face-to face follow up. If there are lower numbers due to the
school not making a strong effort to contact each parent they will be asked to do home visits as a follow up. If a parent
has been properly given the opportunity to respond and chooses to not do so that will be recorded. When BIE is unable
to achieve desired responses from parents, the reporting will identify schools in which there was less than 60%
participation so results can be interpreted accordingly. Example: If all schools except those on Hopi get a response rate
of at least 60% the report will include as a limitation that the general conclusions may not apply to Hopi. If there is a
lower than desired response rate overall for one or more items these will be identified in the report and if statistically
warranted, will be identified as a limitation in results that must be taken into account in interpretation of the resultant
data.

DI-4010 (Rev. 07/2018)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 10/31/2021

17. Federal Cost: (Consult your Bureau/Office Information Collection Clearance Officer for assistance, if necessary)
The estimated annual cost to the Federal government is $ 100.00

, based on: (provide details below)

Sample Response:
“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. 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. The existence of this form actually
saves the government money by standardizing submissions and decreasing the workload of processing each one.”
18. The survey methodology presented in form DI-4010 includes a specific description of:
The respondent universe,
The sampling plan and all sampling procedures, including how respondents will be selected,
How the instrument will be administered,
Expected response rate and confidence levels,
Strategies for dealing with potential non-response bias,
A description of any pre-testing and peer review of the methods and/or the instrument is highly recommended,
The burden hours reported in the Justification include the number of burden hours associated with the initial contact of all
individuals in the sample (i.e., including refusals), if applicable, and the number of burden hours associated with individuals
expected to complete the survey instrument, and
The package is properly formatted (using MS Word) and submitted to the Office of Policy Analysis (through the Bureau/Office
Information Collection Clearance Officer).
19. The approval package includes:
A completed and signed Form DI-4010, Generic Clearance for Customer Satisfaction Surveys.
A copy of the survey instrument.
Other supporting materials, such as:
• Cover letters to accompany mail-back questionnaires,
• Introductory scripts for initial contact of respondents,
• Necessary Paperwork Reduction Act and Estimated Burden compliance language, and/or
• Follow-up letters/reminders sent to respondents.
20. Checklist for Submitting a Request to Use DOI Programmatic Clearance for Customer Satisfaction Surveys
All questions in the survey instrument are within the scope of one of the DOI Programmatic Clearance for Customer
Satisfaction Surveys topic areas.
A qualified statistician has reviewed and approved your request (see question 21A).
Your Bureau/Office Information Collection Clearance Officer receives your package for review/approval at least 75 days
prior to the first day the PI wishes to administer the survey to the public.
21. Required Certifications for Submission Under OMB Control Number 1040-0001
Certification is required to submit a collection of information for approval under the DOI Programmatic Clearance for Customer
Satisfaction Surveys. If the collection does not satisfy the requirements of the Programmatic Clearance, you should follow the
regular PRA clearance procedures described in 5 CFR 1320.
21A. Bureau/Office Statistician
Signature
Date
Recommend

Not Recommended

21B. Bureau/Office Program or Subgroup

Bureau/Office Point-of-Contact

Title (Please be specific)

Signature

Date

FOR PROGRAM USE ONLY
Required certifications: The information collection requested by this submission meets the requirements of OMB Control No. 1040-0001

Bureau/Office ICCO
Recommend

Signature
Signature

Date

10/18/18

Not Recommended

DOI PRA Program Lead
Approved

10/18/18

Not Recommended

DOI Office of Policy Analysis
Recommend

Date

Not Approved

DOI Tracking No.

2018-BIA-CS2

Signature

JEFFREY PARRILLO

Date
Digitally signed by JEFFREY PARRILLO
Date: 2018.10.18 13:20:15 -04'00'

10/18/18

Page 4 of 6

DI-4010 (Rev. 07/2018)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 10/31/2021

Instructions for Completing Form DI-4010,
Justification for Submission Under the
“DOI Programmatic Clearance for Customer Satisfaction Surveys”
OMB Control Number 1040-0001
1.

Bureau/Office: Insert the name of the bureau/office conducting the survey.

2.

Date Submitted: Date you submit the package to the Bureau/Office Information Collection Clearance Officer (ICCO) for review.

3.

Survey Title: Insert title for the proposed survey.

4.

Abstract: Summarize the proposed study with an abstract not to exceed 150 words.

5.

Bureau/Office Point of Contact Information: Complete the bureau/office contact information. PPA will communicate with the
point of contact listed here throughout the entire approval process.

6.

Principal Investigator (PI) Conducting the Survey: Complete information about the PI who will be conducting the survey, if
different from Point of Contact listed in #4. Otherwise note: Same as #4.

7.

Name of Program Office Conducting Survey: Provide the name of the bureau program, office, or organizational unit conducting
the survey.

8.

Description of Customers and Services Provided: Provide a brief description of the customers you will survey, the services
provided by the program conducting the survey, and customers receive these services.

9.

Survey Dates: List the time-period in which you will conduct the survey, including specific starting and ending dates. The starting
date should be at least 75 days after the date you submit the package to your bureau/office Information Collection Clearance
Officer (ICCO).

10. Type of Information Collection Instrument: Check the type(s) of information collection instrument(s) you will use. If other,
please explain.
11. Survey Development: Explain how the survey was developed. With whom did you consult during the development of the survey
on content? On statistics? Did you pretest the survey? What actions did you take to improve the survey? What suggestions did
you receive for improving the survey? Which of the six topic areas will the collection address? (Note: A description of any pretesting and peer review of the methods and/or instrument is highly recommended.)
12. Survey Methodology: Explain how you will conduct the survey. Provide a description of the survey methodology including:
•
Question 12A – The respondent universe,
•
Question 12B – The sampling plan and all sampling procedures;
•
Question 12C – How the instrument will be administered;
•
Question 12D – Expected response rate and confidence levels;
•
Question 12E – Strategies for dealing with potential non-response bias; and,
•
Question 12A – Description of any pre-testing and peer review of the methods and/or instrument (recommended, but not
required).
Note: Web-based surveys are not an acceptable method of sampling a broad population. Web-based surveys must be limited to
services provided by the web site.
13. Burden Hours Calculations: Provide an estimated total of the following for each category – initial contact and completion of
survey instrument:
•
Number of annual respondents – Enter the number of unique respondents who will complete the information collection;
•
Number of responses per respondent – Enter the total number of responses per unique respondent;
•
Total annual responses – Enter the number of unique respondents multiplied by the total number of responses each;
•
Time per response – Estimate the time to complete the initial contact and the time to complete the survey instrument (in
minutes), and
•
Total burden hours –The total burden hours should account for the amount of time required to instruct the respondents in
completing the survey, and the amount of time required for the respondent to complete the survey.
14. Federal Enterprise Architecture (FEA) Business Reference Model: Using the drop-down menus provided, select ONE “Line of
Business” and ONE corresponding Subfunction that most accurately describes your information collection.
15. Reporting Plan: Provide a brief description of the reporting plan for the data you will collect.
Page 5 of 6

DI-4010 (Rev. 07/2018)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 10/31/2021

16. Justification, Purpose and Use: For questions 16A through 16F, provide a brief justification for the survey, its purpose, goals,
and utility to managers. Specifically, describe how you will tabulate the data and what the statistical techniques you will use to
generalize the results to the entire customer population. Describe how you will use the data from the survey. Describe how you
will acknowledge any limitations related to the data, particularly in cases where we obtain a lower than anticipated response rate.
Note whether you intend the survey to measure a Government Performance and Results Act (GPRA) performance measure.
17. Federal Cost: Provide the cost estimate for the Federal government to administer the information collection, along with a
description of how you calculated the cost estimate (sample response provided). Contact your bureau/office ICCO for more
information or for assistance.
18. Survey Methodology Checklist: Carefully review each item and check each box to indicate your submission provides
the required description of each item.
19. Checklist for Submitting a Request to Use DOI Programmatic Clearance for Customer Satisfaction Surveys: Carefully
review each item and check each box to indicate your understanding and concurrence of each requirement.
20. Approval Package Content: Carefully review each item and check each box to indicate your package contains each of the
requirement elements listed.
NOTE: Your survey instrument document must show the OMB Control Number 1040-0001 and Expiration Date ##/##/###, and it
MUST include the following Statements somewhere on the instrument document (preferably at the bottom of page 1 or at the end
of the document):
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 results we
will not share them 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 1040-0001, which expires ##/##/####.
Estimated Burden Statement: We estimate the [insert type of instrument] will take you ## minutes to complete,
including time to read instructions, gather information, and complete and submit your response. You may submit
comments on any aspect of this information collection to the Information Collection Clearance Officer, [Insert
Bureau/Office], [Insert mailing address].
21. Required Certifications: Completion of all information in this section is required before forwarding your approval
package to your bureau/office ICCO for review and processing.
Question 21A – Ensure the bureau/office statistician reviewing your information collection certifies the request satisfies
the requirements of the DOI Programmatic Clearance for Customer Satisfaction Surveys under OMB Control No. 10400001.
Question 21B – Ensure the requestor provides the requested contact information needed by the bureau/office and/or
Departmental ICCO to resolve questions or concerns.

Page 6 of 6