A-11 Fast-Track Clearance Request Template

Request for Approval under the “Generic Clearance for Improving Customer Experience (OMB Circular A-11, Section 280 Implementation)” (OMB Control Number: 2900-XXXX)

TITLE OF INFORMATION COLLECTION:

PURPOSE:

DESCRIPTION OF RESPONDENTS:

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] 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. Personally identifiable information (PII) is collected only to the extent necessary and is not retained.

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

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.

7. All or a subset of information may be released as part of A-11, Section 280 requirements on performance.gov. Additionally, summaries of the data may be released to the public in communications to Congress, the media and other releases disseminated by VEO, consistent with the Information Quality Act.

Name:________________________________________________

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

Personally Identifiable Information:

1. Will this survey use individualized links, through which VA can identify particular respondents even if they do not provide their name or other personally identifiable information on the survey? [ ] Yes [ ] No

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

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

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

Gifts or Payments:

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

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time ( X minutes =)	Burden (÷ 60 =)
Individuals & Households
VA Form (if applicable)
Totals

Please answer the following questions.

1. Are you conducting a focus group, a survey that does not employ random sampling, user testing or any data collection method that does not employ statistical methods?

[ ] Yes [ ] No

If Yes, please answer questions 1a-1c, 2 and 3.

If No, please answer or attach supporting documentation that answers questions 2-8.

1. Please provide a description of how you plan to identify your potential group of respondents and how you will select them.

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

2. Please provide an estimated annual cost to the Federal government to conduct this data collection: ____________

3. Please make sure that all instruments, instructions, and scripts are submitted with the request. This includes questionnaires, interviewer manuals (if using interviewers or facilitators), all response options for questions that require respondents to select a response from a group of options, invitations given to potential respondents, instructions for completing the data collection or additional follow-up requests for the data collection.

4. Describe (including a numerical estimate) the potential respondent universe and any sampling or other respondent selection methods to be used. Data on the number of entities (e.g., establishments, State and local government units, households, or persons) in the universe covered by the collection and in the corresponding sample are to be provided in tabular form for the universe as a whole and for each of the strata in the proposed sample. Indicate expected response rates for the collection as a whole. If the collection had been conducted previously, include the actual response rate achieved during the last collection.

5. Describe the procedures for the collection of information, including:

   1. Statistical methodology for stratification and sample selection.

   2. Estimation procedure.

   3. Degree of accuracy needed for the purpose described in the justification.

   4. Unusual problems requiring specialized sampling procedures.

   5. Any use of periodic (less frequent than annual) data collection cycles to reduce burden.

6. Describe methods to maximize response rates and to deal with issues of nonresponse. The accuracy and reliability of information collected must be shown to be adequate for intended uses. For collections based on sampling, a special justification must be provided for any collection that will not yield "reliable" data that can be generalized to the universe studied.

7. Describe any tests of procedures or methods to be undertaken. Testing is encouraged as an effective means of refining collections of information to minimize burden and improve utility. Tests must be approved if they call for answers to identical questions from 10 or more respondents. A proposed test or set of tests may be submitted for approval separately or in combination with the main collection of information.

8. Provide the name and telephone number of individuals consulted on statistical aspects of the design and the name of the agency unit, contractors, grantees, or other person(s) who will actually collect or analyze the information for the agency.

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

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: Provide answers to the questions. 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.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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 the answer is yes, to the first question, 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.

Submit all instruments, instructions, and scripts are submitted with the request.

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