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 Land Management (BLM)

02/21/19

3. Survey Title
BLM Visitor Satisfaction Survey

4. Abstract (Not to exceed 150 words)
The purpose of the BLM Visitor Satisfaction Survey is to measure visitors’ opinions about BLM facilities, services, and recreational
opportunities. This effort helps us meet requirements of the Government Performance and Results Act of 1993 (GPRA) and other
BLM and Department of the Interior (DOI) strategic planning efforts. The results are used to measure performance related to the BLM
GPRA goals regarding visitor satisfaction, BLM and DOI recreation performance measures, and by BLM managers to improve
services and recreational opportunities provided to visitors, while protecting BLM resources.

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

Last Name

Kimberly

Leitzinger

Title

Bureau/Office

Outdoor Recreation Planner

BLM- National Operations Center

Mailing Address

City

DFC Building 50, PO Bo 25047

Denver

Phone
970-309-0348

■

Work
Cell

Fax

Last Name
Le

Title
Director

Bureau/Office
Washington State University - SESRC

Mailing Address
Wilson-Short Hall #133, PO Box 644014

City
Pullman

Phone
(509) 335-1511

Email
[email protected]

Fax

Zip Code

CO

80225

State
WA

Zip Code
99164-4014

Email
[email protected]

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

Work
Cell

State

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

Bureau of Land Management Washington Offices Management Systems (WO 830) and National Recreation and Visitor Services Division (WO 2

8. Description of Customers and Services Provided

Customers: Recreation visitors and natural, cultural, and heritage tourists to BLM lands.
Services: BLM provides a host of services ranging from protecting natural and cultural resources to offering recreation and tourism
such as facility/trail/road maintenance, visitor information, interpretive and educational materials, and general recreation use
management.
9. Survey Dates
(mm/dd/yyyy)
(mm/dd/yyyy)
09/30/2021
to
03/01/2019
10. Type of Information Collection Instrument (Check ALL that Apply)
Intercept

Telephone

Mail

Web-based

Comment Cards

Other: (Explain) The survey will be a self-administered; the on-site survey is handed to people at specified locatio
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?)
This survey is the culmination of experience gained in using two prior approved versions. The first version of this survey that included non-GPRA items was created with input from customer focus groups, program staff at the field level and program leads at the state and national levels respectively. This
first version survey was developed and tested with assistance from Kevin Coray, Ph.D., of Coray Gurnitz Consulting, Inc. This survey was successfully administered from 1999 to 2001 and 2003-2004. The second version of the survey instrument and the associated methodology were developed in
consultation with the University of Idaho Park Studies Unit (UI PSU), specifically Steve Hollenhorst, Ph.D., Director, National Park Service Visitor Services Project/Associate Dean for Outreach and Engagement, Jennifer Hoger-Russell, M.S., Research Scientist/Principal Investigator, and Yen “Lena” Le,
Ph.D., Research Scientist/Statistician. Brian Forist, Senior Research Associate with the National Park Service’s Social Science Program (2005) also provided input. This survey instrument and methodology was developed with the UI PSU staff identified in the previous paragraph. This survey
instrument includes two new satisfaction-based questions required to meet the BLM’s GPRA reporting requirements.
Since 2014, the survey instrument and procedure had been revised and improved with feedback from the site coordinators and BLM Outdoor Recreational Planners David Baker, and Keith Brown. The revised instrument and procedures were approved in a 2015 renewal. Currently, the survey is
conducted in collaboration with Dr. Lena Le, Director of the Social and Economic Sciences Research Center at Washington State University.
This instrument and methodology meet the Department of the Interior (DOI) guidelines for the generic clearance for customer satisfaction surveys and the GPRA reporting requirements. This instrument retains the previous customer satisfaction items used to comply with GPRA reporting requirements
along with a few demographic questions (number in group, gender, age and zip code) that are used to perform non-response bias checks. Retaining the original satisfaction questions allows for long-term consistency and for tracking trends in comparison to the results obtained under previous versions
of the survey. The continuation of the demographic questions provides the recreation site managers with basic information about which types of visitors are satisfied with which facilities, services, and recreational opportunities in effort to better meet their needs. This limited demographic information
also allows the BLM to assess survey non-response bias.

12. Survey Methodology (Use as much space as needed; if necessary, include additional explanation on separate page.)
12A. Respondent Universe

The population to sample is defined as all visitors, 18 years and older, at approximately 20-25 BLM sites annually each
fiscal year.
12B. Sampling Plan/Procedure
This will be an intercept, comment card survey. The instrument is considered a comment card because it is a one-time survey, with no follow up and no application of the Dillman method. Intercept surveys are an effective method for both reaching this type of customer segment and for obtaining a
maximum response rate when contact information (i.e. name, phone number, mail address, email address, etc.) is not collected. Surveys will be distributed on-site by a trained survey technician (BLM employees or uniformed volunteers). Respondents will be given time and privacy to fill out the survey
before depositing it into a locked drop box. The Principal Investigator (PI), the Social and Economic Sciences Research Center (SESRC) at Washington State University will provide locked drop boxes for survey collection. BLM employees and volunteers will not have the ability to open the locked
boxes. Past experience with this methodology strongly suggests that the face-to-face contact combined with on-site completion of the survey increases the response rate significantly. Instructions and guidelines will be issued to BLM staff at each site to explain proper sampling procedures in order to
achieve the most representative and random sample possible. Included in these instructions will be procedures for recording the number of contacts with potential respondents, the number of refusals, and the number of surveys distributed.
Each location will administer the survey at a time best suited for its needs, usually during a high-usage part of the recreation season and for a set period of time (i.e. two months with a proportional number of weekdays and weekends). After completion of the survey period the BLM staff will mail the
locked drop boxes containing the surveys to the project PI for data entry and analysis. Given past experience with the survey, the response rate is expected to be 70% at a minimum.

12C. Instrument Administration

Daily
starttechnician
and end times
samplingatwill
be flexible
to coincide
historical
patternstime
of use
each
location,
or when
not available
by staff’s selection
best judgment
of use
patterns.
A survey
will beforstationed
a primary
location
during with
the optimal
sampling
for at
that
location.
During
sampling
times, systematic
of visitors
(e.g.,
every nth individual selected) will vary depending on use levels and season. Only one individual per group will be asked to participate.
Individuals chosen for surveying will be informed that the BLM is conducting a visitor study. Using a script as a guide, the survey technician will explain that the purpose of the survey is to measure overall satisfaction of visitors and results will guide future management of the BLM lands. Visitors will be
told that participation is voluntary and responses will be confidential and anonymous. The survey technician will select the nth person (18 years or older). Those who agree will receive a clipboard and pencil with a copy of the survey. The visitor will complete the survey on his/her own with accorded
privacy at the point of interception and deposit it directly into a locked metal drop box. The survey technician will collect the following information in a survey log:
● Date
● Start and end times for each location
● Number of people approached to take survey
● Number of refusals
● Weather conditions
●
General observations
of procedures
Surveys
will be distributed
to approximately 5,000 individuals (between 125 and 400 surveys in each of 20-25 BLM sites). Based on administration of the past survey version, a minimum of 3,500 responses is expected (70%

12D. Expected Response Rate and Confidence Levels

response rate) - actual response rate with the previous survey version and methodology has been 83%. This response rate is very high compared to customer service evaluations in the private sector using comment cards.
This high response rate may be attributed to the personal contact from a survey technician and the survey methodology requiring the survey to be completed and collected at the time of interception.

12E. Strategies for dealing with potential non-response bias
At selected sites on specific sampling days, the demographics of individuals who refuse the survey will be collected via a very short (3 question) interview and recorded on a separate tally sheet (Appendix 4). Demographic
questions in the short interview ask group size, zip code, and overall satisfaction at the location. Gender will be observed. For those who do complete the survey, this demographic information is collected via the survey
instrument. Following the completion of the survey season, the data will be analyzed to determine if a non-response bias exists. If detected, steps to reduce the bias level will be implemented in future survey seasons.

12F. Description of any pre-testing and peer review of the methods and/or instrument (recommended)
The first version of the survey was created with input from customer focus groups, program staff at the field level and program leads at the state and national levels, and university researchers. The survey instrument was developed and tested with assistance from Coray Gurnitz Consulting, Inc. The
survey was successfully conducted from 1999-2001 and from 2003-2004.
The proposed version of the survey and methodology has been developed in consultation with researchers at the UI PSU to add two questions to meet GPRA reporting requirements. The previous version of the survey was approved under OMB control #1040-0001 and had been administered with
great success and has a response rate of 83%. The National Park Service has successfully used a similar methodology since 1998.
The revised instrument and procedure had been approved in 2015 under OMB clearance #1040-0001 and continued with high response rate of 85%.

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

5,000

5,000

5,000

1

83

Completion of Survey Instrument

3,500

3,500

3,500

8

467

Totals: 5,000

5,000

550

Page 2 of 6

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

Transportation
Recreational Resource Management and Tourism

Workforce
Management
15. Reporting Plan

(Select One)

(Select One)

(Select One)

The SESRC at Washington State University will provide the BLM with a National Report as well as summary
reports for each location.
16. Justification, Purpose, and Use
16A. Survey Justification and Purpose
The Government Performance and Results Act of 1993 (P.L. 103-62) requires that the BLM develop goals to improve program effectiveness and public accountability, and to measure performance related to these goals. This visitor satisfaction survey measures the performance toward those goals
through a short scannable visitor survey.
The BLM has a need to better understand visitors so that limited agency staff and budget resources can be most effectively applied in providing for quality recreation opportunities. The purpose of the study is to gain baseline and trend information on levels of satisfaction of visitors seeking outdoor
recreation opportunities on BLM lands. The survey also provides site managers with information about the strengths and weaknesses of visitor service at the site, the service needs of visitors, as well as ideas and suggestions for improving customer service (see open-ended questions at the end of the
survey – Appendix 2).
Data from the survey are needed to assess performance on BLM GPRA goals 1.3.08, 3.1.02, 3.1.11, and 3.2.01. These goals are tied to DOI Strategic Plan as follows:

16B. Survey Goals

DOI Mission Area 1: Conserving our Land and Water
-Goal
To conduct
scientifically
sound
annual
satisfaction
study
of BLM recreation
visitors.
1: Utilizea science
in land,
water,
species
and habitat
management
supporting
decisions and activities.
-Strategy
To better
the level ofofvisitor
withstreams
a rangeand
of offerings
(facilities,
interpretation
products,
road and trail
the purpose
of allocating
agency resources
to opportunities
maintain or improve
the quality
of recreation opportunities and experiences on BLM Lands.
2:understand
Provide stewardship
land, satisfaction
surface water,
shorelines.
The DOI
aims to balance
the conservation
ofmaintenance,
special placesetc.)
withfor
resource
development
whilelimited
also providing
visitors with
for outdoor
recreation.
-BLM
To better
understand the
strengths
and weaknesses
services
at thedesired
site level
and at an overall national level.
Key Performance
Indicator:
Percent
of DOI acresofthat
have both
achieved
conditions.
- To meet BLM GPRA performance requirements.
DOI Mission Area 2: Generating Revenue and Utilizing Our Natural Resources
Goal 3: Ensure public receives fair market value for resources; and recover costs where appropriate.
Strategy 2: Ensure effective collection and application of recreation fees.
BLM Key Performance Indicator: Reviews of fees and changes by DOI.

16C. Utility to Managers

DOI Mission Area 3: Expanding Outdoor Recreation and Access

The
of thisfishing,
studyand
willother
provide
managers
with
baseline information about visitor satisfaction with current opportunities, information, education/interpretive programs, facilities, and value for fee paid. The survey
Goal 1:results
Expand hunting,
recreation
on DOI lands
and waters.
Strategy 1: Promote
hunting, fishing,
other recreation
on DOIthe
lands
and waters. and weaknesses of visitor service at the site, the service needs of the visitors, some demographic characteristics of who their visitors are, as well as ideas
provides
site managers
withand
information
about
strengths
BLM Key Performance Indicators: Number of legal public access transactions completed that facilitate open access to recreation opportunities; Number of newly installed campsites, restrooms, and other facilities that promote public access to BLM-managed public lands; Number of individuals
and
suggestions
for improving
service (see open-ended questions at the end of the survey - Appendix 2). This information will support planning as outlined in the DOI Strategic Plan. Field office and site
participating
in outdoor recreation
activitiescustomer
at special events.
Goal 2: Enhance
public
at DOI
sites.
managers
will
be satisfaction
able to use
this
information to allocate limited agency resource to improve performance where satisfaction levels are low.
Strategy 1: Enhance the enjoyment and appreciation of our natural and cultural heritage.
BLM Key Performance Indicators: Percent of visitors satisfied with the quality of the experience; Percent of visitors satisfied with facilitated programs.

16D. How will the results of the survey be analyzed and used?

Basic descriptive statistics (frequencies, measures of central tendency) will be provided for all questions. Close-ended questions will be scanned and analyzed using SPSS software and, where
practical, frequency data will be presented graphically. Responses to open-ended questions will be provided verbatim to field and site managers. Site specific reports will be distributed to the
participating offices and the Washington Office. Additionally, the WO will receive a national-level report; all reports are posted on the SESRC web site at: https://sesrc.wsu.edu/blm/

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.)
Returned surveys will be electronically scanned and the data analyzed. Responses from individual sites in the system will be combined into one dataset. Data from sites with less than 30 returned survey cards, or from sites with discrepancies in the data collection methods will be omitted from the
system report. Frequency distribution will be calculated for each indicator and category.
Limitations of the use of the data will be clearly conveyed in the report documents. Reports will convey to the reader that the results do not necessarily apply to visitors during other times of the year, to visitors who did not visit the survey locations, or to other units in the system that did not participate in
the survey.
Historically this survey has not had difficulties with low response rates, however, if a low response was encountered the report would indicate this with specific language noting that low survey response rates increase the probability of non- response bias. Non-response bias occurs when those who
choose to participate in a survey differ substantially and systematically from those who choose not to participate. If these differences are related to GPRA measures, the results may be unreliable.

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.)
The following are the relevant DOI Strategic Goals, End Outcomes, and BLM Measures as identified in the U.S. Department of the Interior Strategic Plan Fiscal Years 2018-2022:
DOI Mission Area 1: Conserving our Land and Water
Goal 1: Utilize science in land, water, species and habitat management supporting decisions and activities.
Strategy 2: Provide stewardship of land, surface water, streams and shorelines.
BLM Key Performance Indicator: Percent of DOI acres that have achieved desired conditions.
DOI Mission Area 2: Generating Revenue and Utilizing Our Natural Resources
Goal 3: Ensure public receives fair market value for resources; and recover costs where appropriate.
Strategy 2: Ensure effective collection and application of recreation fees.
BLM Key Performance Indicator: Reviews of fees and changes by DOI.

Page 3 of 6

DOI Mission Area 3: Expanding Outdoor Recreation and Access
Goal 1: Expand hunting, fishing, and other recreation on DOI lands and waters.
Strategy 1: Promote hunting, fishing, and other recreation on DOI lands and waters.
BLM Key Performance Indicators: Number of legal public access transactions completed that facilitate open access to recreation opportunities; Number of newly installed campsites, restrooms, and other facilities that promote public access to BLM-managed public lands; Number of individuals
participating in outdoor recreation activities at special events.

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 $ 65,000.00

, based on: (provide details below)

The costs of survey materials, data processing, generating reports and survey management is approximating $2,955 on average per
BLM site. Annually the survey will be conducted at 22-25 sites. The total cost thus is $65,000 annually.
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

Lena Le

21B. Bureau/Office Program or Subgroup

Bureau/Office Point-of-Contact

BLM NOC Recreation

Kimberly Leitzinger

Title (Please be specific)

Digitally signed by Lena Le
Date: 2019.02.22 13:53:01 -08'00'

Signature

KIMBERLY LEITZINGER

Outdoor Recreation Planner

Date
Digitally signed by KIMBERLY LEITZINGER
Date: 2019.02.22 17:00:45 -07'00'

2/22/19

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
Not Recommended

DOI Office of Policy Analysis
Recommend
Approved

Signature

Not Recommended

DOI PRA Program Lead
Not Approved

JEAN SONNEMAN

Date
Digitally signed by JEAN SONNEMAN
Date: 2019.02.25 12:28:01 -05'00'

DOI Tracking No.

2019-BLM-CS4

BENJAMIN SIMON

Date
Digitally signed by BENJAMIN SIMON
Date: 2019.03.04 08:24:55 -05'00'

Signature

JEFFREY PARRILLO

2/25/19

3/4/19
Date

Digitally signed by JEFFREY PARRILLO
Date: 2019.03.04 09:48:53 -05'00'

3/4/19

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