Generic IC submission Template

BUREAU OF CONSUMER FINANCIAL PROTECTION

Request for Approval under the “Generic Information Collection Plan to Conduct Cognitive and Pilot Testing of Research Methods, Instruments, and Forms” (OMB Control Number: 3170-0055)

PART A. GENERAL INFORMATION

1. Title of the Information Collection (Study):

2. Study Abstract:

3. Type of Collection:

1. Will there be an informed consent? [ ] Yes [ ] No [ ] N/A

Explain why or why not an informed consent is being used.

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

[ ] Cognitive Laboratory Study [ ] Pilot Testing

_{[ ] Other, Explain ______________________}

3. Will interviewers or facilitators be used? [ ] Yes [ ] No [ ] N/A

4. Personally Identifiable Information:

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

1. If yes, describe what PII collected, why it is needed and intended uses.

2. 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

1. If Applicable, has a System or Records Notice (SORN) been published?

[ ] Yes [ ] No

2. If Yes, provide SORN title and Federal Register citation for the SORN __ FR ______

Title: __________________________________________________________________.

3. 1. Has the Privacy Impact Assessment (PIA) been published?

[ ] Yes [ ] No [ ] Not Applicable

2. If Yes, provide link to Privacy Impact Analysis (PIA). If No, please describe that status of the PIA:

PART B. JUSTIFICATION

1. Purpose of the Study and Intended Uses of the Data:

2. Payments or Gifts (Incentives) to Respondents:

3. Assurances of Confidentiality and Justification for Sensitive Questions:

4. Estimated Burden of Information Collection:

Information Collection	No. of Respondents	Frequency (Response per Respondent)	Total Annual Responses	Average Response Time (hours)	Total Burden Hours
[Delete or insert rows as needed]
Totals:	//////////////////	////////////////		///////////////

$

5. Federal Costs (estimated annual cost to the Federal government):

PART C. STATISTICAL METHODS

1. Respondent Universe and Selection Methods:

2. Information Collection Procedures:

3. Testing of Procedures or Methods:

4. Contact Information for Statistical Aspects of the Design:

PART D. 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:

1. It is necessary for the proper performance of agency functions;

2. It avoids unnecessary duplication;

3. It uses plain, coherent, and unambiguous terminology that is understandable to respondents;

4. Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

5. It indicates the retention period for recordkeeping requirements;

6. 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;

7. 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;

8. It uses effective and efficient statistical survey methodology; and

9. It makes appropriate use of information technology.

PART E. CERTIFICATION FOR INFORMATION COLLECTIONS SUBMITTED UNDER A GENERIC INFORMATION COLLECTION PLAN

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 collection is not intended to be published to the public as an official government statistic to be externally valid and representative of a population of interest. The results are intended to be internally valid, not necessarily externally valid.

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 topics or issues being studied.

7. The results will not be used to measure regulatory compliance or for CFPB program performance evaluation.

8. The results are not intended to be generalizable or otherwise draw inferences beyond the survey population.

Page 8 of 8