IC Submission Template

BUREAU OF CONSUMER FINANCIAL PROTECTION
REQUEST FOR APPROVAL UNDER THE
“GENERIC INFORMATION COLLECTION PLAN FOR QUALITATIVE CONSUMER
EDUCATION, ENGAGEMENT, AND EXPERIENCE INFORMATION
COLLECTIONS”
(OMB Control Number: 3170-0036)
1. TITLE OF INFORMATION COLLECTION:
2. PURPOSE:
3. DESCRIPTION OF RESPONDENTS:
4. TYPE OF COLLECTION (ADMINISTRATION OF THE COLLECTION
INSTRUMENT):
a.

How will you collect the information? Check all that apply.
[
[
[
[

b.

] Web-based or other forms of Social Media
[ ] Telephone
] In-person
[ ] Mail
] Small Discussion Group
[ ] Focus Group
] Other (please explain) __________________________________

Will interviewers or facilitators be used?
[ ] Yes [ ] No [ ] Not Applicable

5. FOCUS GROUP OR SURVEY:
If you plan to conduct a focus group or survey, please provide answers to the following
questions:
a. Do you have a customer list or something similar that defines the universe of potential
respondents and do you have a sampling plan for selecting from this universe?
[ ] Yes [ ] No [ ] Not Applicable
b. If yes, please provide a description below. If no, please provide a description of how you
plan to identify your potential group of respondents and how you will select them.
6. INFORMATION COLLECTION PROCEDURES:
Please summarize the procedures that will be used to collect data from respondents.

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7. PERSONALLY IDENTIFIABLE INFORMATION:
a. Is personally identifiable information (PII) collected? [ ] Yes [ ] No
b. If yes, is the information that will be collected included in records that are subject to the
Privacy Act of 1974?
[ ] Yes [ ] No [ ] Not Applicable
c. Has a System or Records Notice (SORN) been published?
[ ] Yes [ ] No [ ] Not Applicable
If yes, list the SORN title and Federal Register citation
Title: ________________________________________________________
__ FR ________________________.
d. If applicable, what is the link to the Privacy Impact Assessment?
8. INCENTIVES:
a. Is an incentive provided to participants? [ ] Yes [ ] No
b. If yes, provide a statement justifying the use and amount of the incentive and the
amount or value of the incentive: $___________.
9. ASSURANCES OF CONFIDENTIALITY:
a. Will a pledge of confidentiality be made to respondents? [ ] Yes [ ] No
b. If yes, please cite the statue, regulation, or contractual terms supporting the pledge.
10. JUSTIFICATION OF SENSITIVE QUESTIONS (if applicable):
11. BURDEN HOURS:
Collection of Information

[Insert rows as needed]
Totals

Number of
Respondents

Frequency

///////////////

Number of
Responses

Response
Time
(hours)
///////////////

12. FEDERAL COST: The estimated annual cost to the Federal government is $________.

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Burden
(hours)

13. CERTIFICATION:
CERTIFICATION PURSUANT TO 5 CFR 1320.9, AND THE RELATED PROVISIONS OF
5 CFR 1320.8(b)(3):
By submitting this document, the Bureau certifies the following to be true:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It uses plain, coherent, and unambiguous terminology that is understandable to
respondents;
(d) Its implementation will be consistent and compatible with current reporting and
recordkeeping practices;
(e) It indicates the retention period for recordkeeping requirements;
(f) It informs respondents of the information called for under 5 CFR 1320.8(b)(3):
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(g) It was developed by an office that has planned and allocated resources for the efficient
and effective management and use of the information to be collected;
(h) It uses effective and efficient statistical survey methodology; and
(i) It makes appropriate use of information technology.
CERTIFICATION FOR INFORMATION COLLECTIONS SUBMITTED UNDER A GENERIC
INFORMATION COLLECTION PLAN
By submitting this document, the Bureau certifies the following to be true:
• The collection is voluntary.
• The collection is low-burden for respondents.
• The collection is non-controversial and does not raise issues of concern to other Federal
agencies.
• Information gathered will not be used for the purpose of substantially informing
influential policy decisions.
• The collection is not statistically significant; the results are not intended to be
generalizable beyond the survey population.
• The results will not be used to measure regulatory compliance or for program
evaluation.

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INSTRUCTIONS
CONSUMER FINANCIAL PROTECTION BUREAU
REQUEST FOR APPROVAL UNDER THE
“GENERIC INFORMATION COLLECTION PLAN FOR QUALITATIVE CONSUMER
EDUCATION, ENGAGEMENT, AND EXPERIENCE INFORMATION COLLECTIONS”
(OMB Control Number: 3170-0036)

1. TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject
of the request. (e.g. Community Education Project Librarian and Patron Interviews). Title should
be that same as the title used for the Data Intake Group review.
2. PURPOSE: Provide a brief description of the purpose of this collection and how it will be
used. If this is part of a larger study or effort, please include this in your explanation.
3. DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group
or groups for this collection of information. These groups must have experience with the
program.
4. TYPE OF COLLECTION: Check all that apply. If you are requesting
approval of other instruments under the generic that are all related, you only
need to complete one form. If you are requesting approval for multiple
unrelated collections then you must complete a form for each instrument.
5. FOCUS GROUPS OR SURVEY: If you are conducting a focus group or survey please
provide answers to the following questions:
a. Identify if you have or will have a list of potential respondents (e.g., conference
participants).
b. The selection of your targeted respondents. Please provide a description of how you
plan to identify your potential group of respondents and how you will select them.
6. INFORMATION COLLECTION PROCEDURES: Please summarize the procedures that
will be used to collect data from respondents.
7. PERSONALLY IDENTIFIABLE INFORMATION (PII): Provide answers to
the questions. Also, if PII will be collected, please consult with the Bureau’s
Privacy office before submitting this request to the PRA Team. If applicable,
provide a link to the Privacy Impact Assessment, list the title of the System of
Records Notice (SORN), and provide the Federal Register cite.
8. INCENTIVES: An incentive is defined as a positive motivational influence; something
that induces action or motivates effort. Incentives are most appropriately used in Federal
statistical surveys with hard-to-find populations or respondents whose failure to participate
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would jeopardize the quality of the survey data. More information on the use of incentives,
please see OMB’s “Guidance on Agency Survey and Statistical Information Collections”
(pages 68-70). This guidance is available on OMB’s website at
http://www.whitehouse.gov/sites/default/files/omb/assets/omb/inforeg/pmc_survey_guidance
_2006.pdf. If you answer yes to the question regarding incentives, please describe the
incentive and provide a justification for the use of an incentive as well as the amount.
Original regulations implementing the 1980 PRA allowed incentives only under
extraordinary circumstances. Current regulations require agencies to provide “an
explanation for a decision for any payment or gift to respondents, other than remuneration
of contractors or grantees” (See 5 CFR 1320.5(a)(1)(iii)(D)).
How to Justify Incentives:
•
•
•
•
•

Demonstrate need for incentives to improve response rates, validity, and reliability.
Demonstrate higher “out-of-pocket” costs to respondent or unusual, intrusive demands.
Provide data showing impact of incentives on response rates, costs, and survey quality.
Conduct experiments to demonstrate whether incentives work as hypothesized.
Demonstrate the cost effectiveness of the incentive (e.g., compared to failed study or
cost to redo the study).
• Demonstrate need due to special populations, such as control groups for longitudinal
studies. (Note: OMB does not accept the use of incentives for recruiting poor and/or
minority groups nor do they accept incentives paid to companies.)
• Consider OMB’s “rule-of-thumb” for incentive amounts (no more than $5 to $10 for
upfront cash incentives for non-in person surveys and $40 to $75 for focus groups).
9. ASSURANCES OF CONFIDENTIALITY: If an assurance of confidentiality is provided,
please cite the authority for such a pledge.
10. JUSTIFICATION OF SENSITIVE QUESTIONS: Please provide a justification for asking
questions that could be considered sensitive in nature (e.g., age, gender, sexual orientation,
income, religion, etc.)
11. BURDEN ESTIMATES:

Collection of Information: List the individual collections that you are requesting to be approved under
this request. For example, phone survey, web survey, training materials evaluation, conference
feedback.
Number of Respondents: Provide an estimate of the Number of respondents.
Participation Time: Provide an estimate of the amount of time required for a respondent to
participate (e.g. fill out a survey or participate in a focus group)
Burden: Provide the Annual burden hours (multiply the number of responses and the
participation time). This estimate should be expressed as hours. Please round to the
nearest whole hour.

12. FEDERAL COST: Provide an estimate of the annual cost to the Federal government for
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conducting the information collection. Do NOT include costs that the Bureau would incur
even without the collection.
13. CERTIFICATION: Please read the certification carefully. If you incorrectly certify,
the collection will be returned as improperly submitted or it will be disapproved.

PAPERWORK REDUCTION ACT STATEMENT FOR THIS CLEARANCE

PAPERWORK REDUCTION ACT
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless it displays a valid OMB
control number. The OMB control number for this collection is 3170-0036. It expires on
8/31/2019. The time required to complete this information collection is estimated to average
approximately [XX minutes/hours] per response. Responding to this collection of information is
voluntary. [This statement can be deleted if noted elsewhere on the instruments] Comments
regarding this collection of information, including the estimated response time, suggestions for
improving the usefulness of the information, or suggestions for reducing the burden to respond to
this collection should be submitted to Bureau at the Consumer Financial Protection Bureau
(Attention: PRA Office), 1700 G Street NW, Washington, DC 20552, or by email to
[email protected].

PLEASE MAKE SURE THAT ALL INSTRUMENTS, INSTRUCTIONS, AND SCRIPTS
ARE SUBMITTED WITH THE REQUEST

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