ICR Template for Agencies A-11

Request for Approval under the “Improving Customer Experience (OMB Circular A-11, Section 280 Implementation)”

(OMB Control Number: 0503-XXXX)

TITLE OF INFORMATION COLLECTION: XXX

PURPOSE:

What are you hoping to learn / improve? How do you plan to use what you learn? Include any artifacts your team may develop (user persona, journey map, design roadmap, data to submit as part of compliance with A-11 CX Feedback data collection) as a result of this collection.

XXX

TYPE OF ACTIVITY: (Check one)

[ ] Customer Research

[ ] Customer Feedback Survey (if selecting this option, include survey instrument tool with this submission, and identify how if at all it deviates from the standard A-11 questions + two free response questions. Your desk officer will need to work with you to determine if non-A-11 questions are ok to report on publicly)

[ ] User Testing of Services and Digital Products

DESCRIPTION OF ACTIVITY

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

For Customer Research and User Testing Services:

Explain who will be interviewed and why the group is appropriate for the Federal program / service to connect with. Do you have a list of customers to reach out to (e.g., intercept interviews at a particular field office)? Please provide a description of how you plan to identify your potential group of respondents and if only a sample will be solicited for feedback, how you will select them.

XXX

Generally describe the information collection activity – e.g. will facilitators or interviewers be used? What will respondents be asked? Or, what actions will you observe / how will you have respondents interact with a product you need feedback on?

XXX

For Customer Feedback Survey:

Explain who will be surveyed and why the group is appropriate for the Federal program / service to connect with. Do you somehow have a list of customers to reach out to (e.g., email addresses of individuals who have visited a service center in the past month)? Please provide a description of how you plan to identify your potential group of respondents and if only a sample will be solicited for feedback, how you will select them.

XXX

Gifts or Payments:

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

CERTIFICATION:

I certify the following to be true:

1. The collections are voluntary;

2. The collections are low-burden for respondents (based on considerations of total burden hours or burden-hours per respondent) and are low-cost for both the respondents and the Federal Government;

3. The collections are non-controversial and do not raise issues of concern to other Federal agencies;

4. Any 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 near future;

5. Personally identifiable information (PII) is collected only to the extent necessary and is not retained;

6. Information gathered is intended to be used for general service improvement and program management purposes

7. Upon agreement between OMB and the agency all or a subset of information may be released as part of A-11, Section 280 requirements only on performance.gov. Summaries of customer research and user testing activities may be included in public-facing customer journey maps.

8. Additional release of data will be coordinated with OMB.

Name:________________________________________________

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden Hours
Totals

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

All instruments used to collect information must include:

OMB Control No. 0503-XXXX

Expiration Date: XX/XX/XXXX

Instructions for completing Request for Approval under the “Improving Customer Experience (OMB Circular A-11, Section 280 Implementation)”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

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.

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.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. 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 and divide by 60.

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If applicable, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

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