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 Affairs, Great Plains Regional Office

10/18/2018

3. Survey Title
Road Maintenance Improvement Project

4. Abstract (Not to exceed 150 words)
The purpose of this survey is to gather information to help understand road maintenance needs and the assets you have available to
maintain roads. The BIA and the Tribal Interior Budget Council sub-Com on Road Maint. (TBIC-RM) is seeking information to help
improve the BIA Roads program. This survey is being distributed to all tribes and BIA agencies that operate a Road Maintenance
program. The data will be analyzed by BIA and TBIC to help inform program decisions.

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

Last Name

Ernest

Pourier

Title

Bureau/Office

Budget Officer

Bureau of Indian Affairs, Great Plains Regional Office

Mailing Address

City

115 4th Avenue, S.E., Suite 400

Aberdeen

Phone

■

(605) 226-7743

Work
Cell

Fax
(605) 226-7741

State
SD

Zip Code
57401

Email
[email protected]

6. Principal Investigation (PI) Point-of-Contact Information
First Name
Daniel

Last Name
Sine

Title
Budget Analyst

Bureau/Office
Bureau of Indian Affairs, Great Plains Regional Office

Mailing Address
115 4th Avenue SE, Suite 400

City
Aberdeen

Phone
(605) 226-7742

Work
Cell

Fax
(605) 226-7741

State
SD

Zip Code
57401

Email
[email protected]
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
TIBC Roads Maintenance Sub-Committee, Great Plains Regional Budget Office

8. Description of Customers and Services Provided

Tribal and Bureau operated Road Maintenance programs

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) https://docs.google.com/forms/d/e/1FAIpQLSf7XwpyQUgfYuATISFCgoolp2Bi9VYqj1FBeGmin1
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?)
The origin of the survey began with members of the tribal road maintenance improvement in the Great Plains Region. Subsequent input was provided by subject matter experts such
as federal highway engineer Tom Croymans in the Great Plains Regional Office and 2 individuals from the Central Office, Mr. LeRoy Gishi and Robert Fraizier. Mr. Dave Kelly, Road
Maintenance Supervisor, of the Oglala Sioux Tribe also provided input. The survey was narrowed down quantitative questions for the overall ease of response and measurement.
The survey will consist of 21 questions, ranging from ranking the top 3 critical road maintenance issues, provide cost per mile based on gravel, earth, asphalt, concrete, does the
program work with state and other agencies to maintain roads and is there data collected regarding maintenance.

12. Survey Methodology (Use as much space as needed; if necessary, include additional explanation on separate page.)
12A. Respondent Universe
The BIA road maintenance program does not operate at all Tribal or Agency locations, but rather at 234 locations out of the 567 federally recognized Tribes. Of these 234 locations,
176 Tribal governments operate the road maintenance program, wherein 58 locations have BIA employees performing the work.

12B. Sampling Plan/Procedure
This is a voluntary and confidential survey that will be sent to all 234 locations via e-mail and administered with the Google survey tool. The survey instrument will utilize Google
software. The sample will consist of only BIA-funded locations.

12C. Instrument Administration

See next page (2A)
12D. Expected Response Rate and Confidence Levels
We anticipate a response rate of 75% because 85% of the BIA-funded road miles are within 6 BIA regions. Each Regional Budget Officer will follow up with the survey respondents in
their region to invite them to complete the survey. Since this survey is administered on the internet via a Google link, this survey will be more user friendly to the respondents.

12E. Strategies for dealing with potential non-response bias

We will monitor completion of the survey through the use of the Google survey.
12F. Description of any pre-testing and peer review of the methods and/or instrument (recommended)

We will pre-test this survey instrument with staff members of the Great Plains Regional office as well as Road
Maintenance Program staff from the Oglala Sioux Tribe of South Dakota not to exceed 10 from that location.
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

234

1

234

15 mins

58.5

Completion of Survey Instrument

175

1

175

15 mins

43.75

Totals: 409

409

102.25

Page 2 of 6

Page 2A - Continuation
12C. Instrument Administration
The Great Plains Regional Office will send out a Google Survey internet link to invite participation. The data
provided in this survey will assist in meeting this goal. Your participation is confidential and voluntary. The Tribal
Interior Budget Council Sub-Committee on the Road Maintenance (TIBC-RM) is a functional work group of the
TRIBAL-INTERIOR BUDGET COUNCIL (TIBC) March 2016 to develop funding and improve the functionality of
the Roads Program within Indian Country.
As with All Functional areas, there is a need to evaluate and develop the Roads Maintenance program. This data
will be provided to the TIBC for their further use. This survey can be found at:
https://docs.google.com/forms/d/e/1FAIpQLSf7XwpyQUgfYuATISFCgoolp2Bi9VYqj1FBeGmin1xj1snsjA/
viewform?usp=sf_link
Results will be tabulated from Google software on-line into an Excel spreadsheet without any staff interaction.
These tabulated results will then be sent to the data analysts and statisticians to compute the data analysis. The
data analysis staff will forward the survey results to the Great Plains Regional Budget Officer in Aberdeen, South
Dakota, who will provide this data to the Tribal Budget Interior Committee Roads Maintenance Sub-Committee.
Milestones
1.
Develop Survey instrument
2.
Pre-test of Survey instrument
3.
Review of Survey by GPRO Budget Officer/ Dave from Oglala Sioux Tribe, Pine Ridge, SD
4.
Forwarding via internet of survey to survey participants
5.
Suspense date of survey completion: August 10, 2017
6.
Consolidation and download of data/data entry into Excel spreadsheets
7.
Forward of Data to statisticians for analysis/
8. Data analysis.
9. Complete write-up summary of analysis
10. Complete summary of statistical methods
11. Reproduce paper / electronic copies
12. Review by 3rd party professional for critique/edit of finished document
13. Edit and correct final changes
14. Devise PowerPoint presentation

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

(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

Ground Transportation

Workforce
Management
15. Reporting Plan

(Select One)

(Select One)

The results will be tabulated and sent to the data analysis/statisticians for analysis. Upon completion, these results will be returned to the Great Plains Regional
Budget Officer who will prepare the presentation to present to the TIBC Roads Maintenance Sub-Committee. The TIBC Roads Maintenance Sub-Committee will
present this material to the TIBC during the General Assembly of TBIC in May, 2018 in Washington, DC.

16. Justification, Purpose, and Use
16A. Survey Justification and Purpose
As with all Functional Areas, evaluation needs to be completed periodically to assess the needs of the serviced reservation and to assess the following aspects of
the road maintenance operations/scope 1) inquiry of operations relating to various metrics, 2) data collection, 3) cost measurement, 4) deferred maintenance
needs, and 5) and how assets relative to roads maintenance.

16B. Survey Goals
To collect baseline data on the extent to which tribes collect data on road maintenance needs, associated, costs, and inflation. Flat line funding is an issue relative to this functional
area and needs to be realized as costs increase in time. In the future, we hope to accumulate data to show this, this survey being a beginning point relative this project.

16C. Utility to Managers

This data is anticipated to be used in future budget requests to support the Roads Maintenance Program.
16D. How will the results of the survey be analyzed and used?
Depending on the question, whether qualitative or quantitative, we will employ the use of histograms, and bar and pie charts to interpret the data. We will also
request descriptive statistics on the quantitative portions of our survey.

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.)

Does not apply.

Page 3 of 6

Page 4A - Continuation
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?
Tabulation and analysis: The data will be tabulated in a spreadsheet and analyzed using techniques appropriate for
each question, depending on whether the question is quantitive or qualatitive.
Limitation: One key limitation of this study is that data is only being collected for a single period of time. This limits the
ability to compare to previous time periods.
1.

2.

Survey Questionnaire
a.

Qualitative measures

b.

Quantitative measures

Needed Analysis
a.

Descriptive Statistics

b.

Univariate Analysis

c.

Correlation

d.

Validity

e.

Crosstabs

f.

Write-up summary of Analysis

g.

Write-up summary of Statistical research methods

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-CS3

Signature

JEFFREY PARRILLO

Date
Digitally signed by JEFFREY PARRILLO
Date: 2018.10.18 14:13:23 -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