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 Reclamation / Policy and Administration/ Asset Management Division

6/25/2019

3. Survey Title

Reclamation Visitor Satisfaction Survey
4. Abstract (Not to exceed 150 words)

The purpose of the Bureau of Reclamation (Reclamation) Visitor Satisfaction Survey is to measure visitors’ opinions
about Reclamation facilities, services, and recreational opportunities. This effort helps Reclamation meet requirements of
the Government Performance and Results Act of 1993 (GPRA) and other Reclamation and Department of the Interior
(DOI) strategic planning efforts. The results are used to measure performance related to the GPRA goal to enhance
public satisfaction at DOI sites and to measure satisfaction with facilitated programs; and by Reclamation managers to
improve services and recreational opportunities provided to visitors.

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

Last Name
Baca

Title
Program Analyst

Bureau/Office
Bureau of Reclamation/ Policy and Administration/Asset Management Divisio

Mailing Address
Bldg. 67, 14th floor, PO BOX 25007 (84-57000)

City
Denver

Phone
303-445-3257

Email
[email protected]

■

Work
Cell

Fax

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

Last Name
Schuster

Title
Branch Chief, Social & Economic Analysis

Bureau/Office
United States Geological Survey

Mailing Address
City
Fort Collins Science Center, U.S. Geological Survey 2150 Centre Ave.,
FortBuilding
Collins C
Phone
970-226-9165

■

Work
Cell

Fax

State
CO

Zip Code
80225

State
CO

Zip Code
80526

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

Bureau of Reclamation Field and Area Offices. Sites will rotate on an annual basis.
8. Description of Customers and Services Provided

The customers will be visitors at Reclamation's direct managed recreation areas that have facilitated programs. The
customers will be 18 years and older.
The surveys are intended to display the percentage of visitor satisfaction and will also be used to determine future
planning and improvement needs.
9. Survey Dates

(mm/dd/yyyy)
Memorial Day (annually)

(mm/dd/yyyy)
Labor Day (annually)

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?)

The Reclamation Visitor Satisfaction Survey was created in partnership with the following staff from the U.S. Geological
Survey, Fort Collins Science Center, Social and Economic Analysis Branch: Dr. Rudy M. Schuster, social scientist; Chris
Huber, economist; and Adam Urpsis, software designer. Karla Rogers, landscape, architect and human ecologist, with the
Bureau of Land Management also provided input.
12. Reclamation
Survey Methodology
(Usedeveloped
as much space
asvisitor
needed;
if necessary,
includecreated
additional
explanation
separate
page.)
The
survey was
using
satisfaction
surveys
and
currentlyon
being
administered
by the
12A.
Respondent
Universe
Bureau of Land Management (BLM) and the National Park Service (NPS) to meet GPRA reporting requirements. The
The
universe
fornumbers
this collection
will be all adults
18 years respectively.
of age or older visiting a Reclamation-direct
BLMrespondent
and NPS OMB
control
are 1040-0001
and 1024-0216
managed recreation area during designated sampling periods. Visitors will be randomly selected to participate in the
study.
This instrument and methodology meet the DOI guidelines for the generic clearance for customer satisfaction surveys and
12B.
Sampling
Plan/Procedure
the
GPRA
reporting
requirements. This instrument consists of customer satisfaction items used to comply with GPRA
This
will be
an on-site intercept
and
format survey.
It is (number
a one-time
surveygender,
where aage
Reclamation
representative
reporting
requirements
along with
a interview
few demographic
questions
in group,
and zip code)
that are
reads
questions
to
a
visitor
at
the
Reclamation
recreation
area.
The
initial
year
of
survey
administration
will
considered
used to perform non-response bias checks. The use of demographic questions provides the recreation sitebe
managers
a
pilot
year.
Not
more
than
20
Reclamation
units
will
be
selected
to
participate
in
the
survey.
Pilot
sites
will
be
selected
to
with basic information about which types of visitors are satisfied with which facilities, services, and recreational
reflect
the
variation
in
management
settings,
activities,
and
site
complexity.
Survey
data
collection
will
be
expanded
to
12C. Instrument
Administration
opportunities
in efforts
to better meet their needs. This limited demographic information also allows Reclamation to
additional
Reclamation
in
the second
year. location during the identified sampling time for that location. During
A survey
technician
will units
be stationed
at a primary
assess
survey
non-response
bias.
sampling times, systematic selection of visitors (e.g., every 5th individual selected) will vary depending on use levels and
The
survey
data
distributed
locations
with high Individuals
concentrations
of visitors
such aswill
popular
boat that
season.
Only
onecollection
individualwill
perbegroup
will beat
asked
to participate.
chosen
for surveying
be informed
launches,
marinas,
trail
heads,
visitor
centers,
and
campgrounds.
The
survey
coordinator
in
each
recreation
area
will of
Reclamation
is conducting
a visitor
UsingLevels
a script as a guide the survey technician will explain that the purpose
12D. Expected
Response Rate
and study.
Confidence
randomly
schedule
the
required
survey
days
(each
having
a
4-hour
time
period)
during
a
high-usage
part
of
the
recreation
the survey
to administered
measure overall
satisfaction of 70
visitors
results
will guide
future management
of Reclamation
Surveys
willisbe
at approximately
sites and
per year.
Based
on OMB-approved
methodology
currentlylands.
used by
season.
There
will be
variation
inwill
number
of sampling
daysa necessary
recreation
area,
on
known
use
levels,
to
Visitors
told
that
participation
is voluntary,
responses
will be
and
anonymous.
survey
technician
the
BLMwill
andbeNPS,
Reclamation
attempt
to administer
total
of confidential
400per
surveys
at each
of based
the 70The
sites.
Variation
in
achieve
the
desired
number
of
responses
per
site.
Sampling
days
will
be
stratified
to
equally
reflect
weekday
and
will select
nthuse
person
(18 exists
years or
older).
For those who
to participate,
the interviewer
will readatthe
questions
amount
of the
visitor
at sites
and
it is anticipated
that agree
an average
of 200 visitors
will be contacted
each
site for to
a
weekend
use.
In
addition,
equal
numbers
of
mornings
and
afternoons
will
be
included
in
the
schedule.
If
sampling
days
the
respondent
and
enter
answers
directly
into
an
electronic
tablet.
All
survey
questions
can
be
found
in
Appendix
1.
For
total
of
14,000
visitor
contacts.
Based
on
response
rates
from
the
BLM
(70%
response
rate)
and
NPS
(55%
response
12E. Strategies for dealing with potential non-response bias
unexpectedly
need
tosurveys,
be
added
(based
on individual
circumstances
such
asrate
visitor
attendance
questions
that
require
choosing
a list
(e.g.
activities
participated
inweather,
today),
the
respondent
willfluctuations,
be
handed
aand
rate)
on satisfaction
weitems
conservatively
ato50%
response
for a total
of 7,000
usable
surveys.
This
All
visitors
refusing
to
participate
in thefrom
study
willanticipate
be asked
respond
to three
non-response
bias questions
(see Item
construction),
sampling
days
will
be
added
to
ensure
a
representative
sample
of
visitors.
flashabove).
card
to is
easily
name
items.
sample
size
considered
to bewill
robust
enough
at both an
and national
to produce
results with
acceptable
12C
These
responses
be used
to evaluate
anyindividual
non-respondent
bias. level
Demographic
questions
in the
short
margins
of
error.
interview ask: year born, zip code, gender, and overall satisfaction at the location. Following the completion of the survey
Initial
contact
made by
Reclamation
in each
ofexists.
the
chosen
units.
This
will the
takebias level
season,
the data
will
be be
analyzed
toand
determine
if aemployees
non-response
bias
If detected,
stepscontact
to reduce
12F. visitor
Description
of will
any
pre-testing
peer review
of the methods
and/or
instrument
(recommended)
approximately
one
minute.
The
responses
to
the
non-response
questions
will
take
an
additional
minute.
will
implemented
in future
seasons.
Thebe
NPS
and BLM have
bothsurvey
used similar
methodology and questions since 1998 and 1999 respectively. All questions
have been used by the BLM and NPS in surveys intended to comply with GPRA requirements. The data collection
Hello, my
name
is ______.
Thewere
Bureau
of Reclamation
is conducting
a brief
survey
of our visitors.responsible
We would like
method
and
survey
questions
developed
in consultation
with BLM
and NPS
representatives
withtotheir
understand
how
satisfied
you
were
with
the
services
and
facilities
here
at
[insert
unit
name].
Your
participation
GPRA
reporting
programs.
An on-site field pilot test was conducted at one Reclamation recreation area. A totalisof eight
13. Burden
Hours
Calculations
voluntary
and
this
will
take
about
eight minutes
of your
time. If you
are survey.
able to complete the survey I will read the
(8) recreational visitors were contacted
and
asked
participate
in the
Number
ofto
Annual
Number
of
Total Annual
Time per
Total Burden
questionsCategory
to you and
record
answers
on
this
electronic
tablet.
Would
you
be willing
to help us byResponse
participating in this
short
of Respondent
Respondents
Responses Each
Responses
Hours
survey?”
1
Initial Contact

14000

14000

1 minutes

233.3

933.3
1
7000 will read the questions
7000answers.
of response
Survey Instrument
8 minutes
IfCompletion
the visitor’s
is “Yes,” the surveyor
and record
If the visitor’s response is “No,” the
surveyor
will continue by asking the visitor
to complete the non-response1173
survey:
21000
21000
Totals:
I understand that you may not have time to complete the full version of the survey. However you be willing to answer
three brief questions that will only take about one minute?
If the visitor’s response is “Yes,” the surveyor will ask the following three questions:
1. If you were to rate overall quality of facilities, services, and recreational opportunities you experienced here today at
Page 2 of 6
[insert unit name]: would you say they were very good, good, average, poor, or very poor?
2. What is your zip code?
3. In what year were you born?

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)

USGS will provide annual reports for each of the surveyed sites and one summary report. Each report will summarize
survey design, methods, and all statistical results. The reports will be modeled after the existing BLM visitor satisfaction
report format and content. The USGS will provide the data in an agreed upon file format (e.g., csv-file, Excel, or similar).
USGS
will also provide
summary
reports for each individual recreation site and one report with results from all sites
16. Justification,
Purpose,
and Use
combined as electronic files.
16A. Survey Justification and Purpose

This survey will be designed to measure visitors' opinions about Reclamation facilities, services, and recreational
opportunities. Results will be used to measure performance against the predefined requirement and goals regarding
visitor satisfaction with recreational opportunities, facilitated programs, facilities, and services which will allow for
improvement
of services and recreational opportunities provided to visitors. This effort helps Reclamation meet the
16B. Survey Goals
requirements of the GPRA as well as future planning efforts.
To obtain the percentage of visitors satisfied with facilitated programs at Reclamation's recreation areas pursuant to the
GPRA performance measures.
16C. Utility to Managers

The survey results will be used to ensure Reclamation meets the public visitor satisfaction goals set by the Secretarial
GPRA requirement. In addition, survey results will also be used as an instrument to aid in the planning and development
efforts of recreation areas to increase overall visitor satisfaction.
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 analyzed using statistical 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, Reclamation Denver Policy and Administration, and the Washington Office.
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.)

All data will be collected electronically using a tablet and approved software. Completed surveys will be transferred from
each tablet to secure storage facilities using approved data transmission and storage processes. Responses from
individual sites in the system will be combined into one dataset. Data from sites with less than 30 completed surveys or
from sites with discrepancies in the data collection methods will be omitted from the system report. Frequency distribution
16F. Is this survey intended to measure a Government Performance and Results Act (GPRA) performance measure? If
will
beplease
calculated
foran
each
indicator
category. document. (Use as much space as needed; if necessary, include additional
yes,
include
excerpt
from and
the appropriate
explanation on separate page.)

Limitations
of the use
dataon
will
be clearly
conveyed
in the
report
documents.
toand
the reader
The
data reported
will of
bethe
based
results
of a survey
of the
adult
American
public Reports
(18 yearswill
oldconvey
or older
residingthat
in
the U.S.).
results Surveys
do not necessarily
apply
to
visitors
during
other
times
of
the
year,
to
visitors
who
did
not
visit
the
survey
will be conducted by sampling the public at the Regional level on an annual basis. The survey will ask
locations,
or to other
in the system
that did programs
not participate
in the survey.
the
public about
their units
satisfaction
with facilitated
at Reclamation
recreation areas. This measure includes all
interpretation and education personal service programs that are offered in a given year. Personal service programs are
Based on
rates from
the BLM
NPS,
this survey
method has
had difficulties
with low
response rates.
defined
asresponse
those programs
in which
staffand
(paid
employees,
volunteers,
andnot
cooperating
association
employees)
interact
However,
if
a
low
response
was
encountered
the
report
would
indicate
this
with
specific
language
noting
that lowPage
survey
with visitors.
3 of 6
response rates increase the probability of non-response bias and the results may be unreliable.
Survey questions will be developed and submitted to the DOI Information Collection Clearance Officer and OMB for

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 $ 10,161.08

, based on: (provide details below)

Assuming that the minimum collection response rate is reached as seen in section 13., the collection of 7,000 usable
surveys across Reclamation is estimated to accrue 933.3 burden hours. The average time to complete a usable survey is
approximately 8 minutes. An additional 233.3 burden hours should be accounted for as a result of the estimated 7,000
respondents
that decline to participate. Should an encounter result in a respondent declining to participate, the encounter
Sample Response:
should
take
approximately
minute.
The
estimated
burden
hours willeach
be 1,166.6.
“If we receive 20 submissions1and
it takes
30total
minutes
to process
and implement
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 thanwill
through
the freeformofsubmissions
would otherwise
in byof
personal
email.1 The
existenceThe
of this
form actually
Surveyors
be comprised
a mixture ofthat
volunteers
and ancome
average
GS-7 Step
employees.
current
base pay
saves
the government
money by
standardizing
decreasing
the workload of processing each one.”
for
a GS-7
Step 1 employee
$17.42
per hoursubmissions
and can beand
viewed
at https://www.opm.gov/policy-data-oversight/pay-leave/
18. The survey methodology presented in form DI-4010
includesthat
a specific
description
of:
salaries-wages/salary-tables/pdf/2019/GS_h.pdf.
It is expected
the mixture
of surveyors
will be close to an equal
■ The respondent universe,
representation
of both Federal employees and volunteers.
■

The sampling plan and all sampling procedures, including how respondents will be selected,

Howhalf
theof
instrument
be administered,
Given■ that
the total will
estimated
burden hours, 583.3, will be completed by volunteers, the total cost to the
■ Expected response rate and confidence levels,
government
will be zero. The remaining 583.3 hours, completed by Federal employees at a rate of $17.42 per hour will
dealingtowith
create■ aStrategies
total costfor
burden
thepotential
Federalnon-response
Governmentbias,
of $10,161.08.
■

■

■

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 of Reclamation

RUDOLPH SCHUSTER

Digitally signed by RUDOLPH SCHUSTER
Date: 2019.07.18 14:47:37 -06'00'

7/18/19

Bureau/Office Point-of-Contact

RONNIE BACA

Title (Please be specific)

Signature

RONNIE BACA

Program Analyst

Date
Digitally signed by RONNIE BACA
Date: 2019.07.18 12:30:48 -06'00'

7/18/19

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

MADONNA BAUCUM

Date
Digitally signed by MADONNA BAUCUM
Date: 2019.07.18 11:12:07 -04'00'

DOI Tracking No.

Not Approved 2019-BOR-CS5

BENJAMIN SIMON

Date
Digitally signed by BENJAMIN SIMON
Date: 2019.07.17 17:56:10 -04'00'

07/17/2019

Digitally signed by JEFFREY PARRILLO
Date: 2019.07.19 07:03:44 -04'00'

7/19/19

Signature

JEFFREY PARRILLO

07/18/2019

Date

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.
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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.

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