Generic One-Page Memo

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

T ITLE OF INFORMATION COLLECTION: Wellness Program Satisfaction Survey

PURPOSE:

As part of the ongoing assessment of the US Army Criminal Investigation Division Command (CIDC) Wellness Program, a satisfaction survey will be implemented in order to garner opinions and recommendations on the progress and direction of the program. This survey is needed to provide feedback to CIDC leadership and the contractor as we continue to ascertain the needs of all personnel who are using the services provided by the program. This survey will be utilized as a voluntary tool for CIDC government contractor employees. The information will be reviewed and provided to the agency’s senior leadership for information/action.

DESCRIPTION OF RESPONDENTS:

CIDC government contractor employees who utilize the services offered through the CIDC Wellness Program.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [X] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [ ] Other: ______________________

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

3. The collection is non-controversial and does not raise issues of concern to other federal agencies.

4. The results are not intended to be disseminated to the public.

5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

Name: MAJ Michelle Miller, Command Forensic Psychologist

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [ X] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ X ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No NA

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [X] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Agency Government Contractor Employees	50	10 minutes	8.33 hours
Totals	50	10 minutes	8.33 hours

FEDERAL COST: The estimated annual cost to the Federal government is $60.39

Cost estimate reached from multiplying 7.25 (federal minimum wage) with 8.33 (total burden hours).

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. 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 [X] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

Wellness Program Satisfaction Surveys will be made available to all CIDC government contractors with participation being strictly voluntary.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[X] Other, Explain: Email link through Survey Monkey. The CIDC research division has a paid subscription to Survey Monkey with HIPAA control features, ensuring that DoD owns the data obtained via the survey.

2. Will interviewers or facilitators be used? [ ] Yes [ X ] No

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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