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pdfDI-4010 (Rev. 03/2021)
U.S. Department of the Interior
JUSTIFICATION FOR SUBMISSION UNDER THE
“DOI PROGRAMMATIC CLEARANCE FOR
CUSTOMER SATISFACTION SURVEYS”
See Page 5 for Instructions on Completing This Form
1. Bureau/Office
OMB Control. No. 1040-0001
Expiration Date ##/##/####
2. Date Submitted
3. Survey Title
4. Abstract (Not to exceed 150 words)
5. Bureau/Office Point-of-Contact Information
First Name
Last Name
Title
Bureau/Office
Mailing Address
City
Phone
Work
Cell
Fax
State
Zip Code
Email
Page 1 of 9
DI-4010 (Rev. 03/2021)
U.S. Department of the Interior
OMB Control. No. 1040-0001
Expiration Date ##/##/####
6. Principal Investigation (PI) Point-of-Contact Information
First Name
Last Name
Title
Bureau/Office
Mailing Address
City
Phone
Work
Cell
Fax
State
Zip Code
Email
7. Name of Program or Office Conducting Survey
8. Description of Customers and Services Provided
9. Survey Dates
(mm/dd/yyyy)
(mm/dd/yyyy)
to
10. Type of Information Collection Instrument (Check ALL that Apply)
Intercept
Telephone
Focus Groups
Other: (Explain)
Mail
Web-based
Comment Cards
11. Survey Development (Who assisted in survey content development statistics? Was the survey pretested? How did you
integrate improvements? Which of the six topic areas did you address?)
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DI-4010 (Rev. 03/2021)
U.S. Department of the Interior
OMB Control. No. 1040-0001
Expiration Date ##/##/####
12. Survey Methodology (Use as much space as needed; if necessary, include additional explanation on separate page.)
12A. Respondent Universe
12B. Sampling Plan/Procedure
12C. Instrument Administration
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DI-4010 (Rev. 03/2021)
U.S. Department of the Interior
OMB Control. No. 1040-0001
Expiration Date ##/##/####
12D. Expected Response Rate and Confidence Levels
12E. Strategies for dealing with potential non-response bias
12F. Description of any pre-testing and peer review of the methods and/or instrument (recommended)
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DI-4010 (Rev. 03/2021)
U.S. Department of the Interior
OMB Control. No. 1040-0001
Expiration Date ##/##/####
13. Burden Hours Calculations
Number of Annual
Respondents
Category of Respondent
Number of
Responses Each
Total Annual
Responses
Time per
Response
Total Burden
Hours
Initial Contact
Completion of Survey Instrument
Totals:
14. Federal Enterprise Architecture (FEA) Business Reference Model (Check only one “Line of Business” and one
“Subfunction.” Refer to OMB guidance “FEA Consolidated Reference Model Document Version 2.3”)
Line of Business
Subfunction
Community and
Social Services
Defense and
National Security
Economic
Development
(Select One)
Line of Business
Subfunction
(Select One)
Correctional
Activities
Disaster
Management
(Select One)
Education
(Select One)
Energy
(Select One)
(Select One)
General Science
and Innovation
Environmental
Management
(Select One)
Health
(Select One)
Homeland Security
(Select One)
Income Security
(Select One)
Intelligence
Operations
(Select One)
Law Enforcement
(Select One)
International Affairs
and Commerce
Litigation and
Judicial Activities
Natural Resources
(Select One)
Transportation
Workforce
Management
15. Reporting Plan
(Select One)
(Select One)
(Select One)
(Select One)
(Select One)
(Select One)
16. Justification, Purpose, and Use
16A. Survey Justification and Purpose
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DI-4010 (Rev. 03/2021)
U.S. Department of the Interior
OMB Control. No. 1040-0001
Expiration Date ##/##/####
16B. Survey Goals
16C. Utility to Managers
16D. How will the results of the survey be analyzed and used?
16E. How will the data be tabulated? How What Statistical Techniques will be used to generalize the results to the entire
customer population? How will limitations on use of data be handled? If the survey results in a lower than anticipated
response rate, how will you address this when reporting the results? (Use as much space as needed; if necessary, include
additional explanation on separate page.)
16F. Is this survey intended to measure a Government Performance and Results Act (GPRA) performance measure? If yes,
please include an excerpt from the appropriate document. (Use as much space as needed; if necessary, include additional
explanation on separate page.)
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DI-4010 (Rev. 03/2021)
U.S. Department of the Interior
OMB Control. No. 1040-0001
Expiration Date ##/##/####
17. Federal Cost: (Consult your Bureau/Office Information Collection Clearance Officer for assistance, if necessary)
The estimated annual cost to the Federal government is $
, based on: (provide details below)
Sample Response:
“If we receive 20 submissions and it takes 30 minutes to process and implement each one, then the total burden is $322.40
assuming a GS-7 step 5 is processing the submissions. This custom form is a tool meant to accept submissions in a standard format
rather than through the freeform submissions that would otherwise come in by personal email. The existence of this form actually
saves the government money by standardizing submissions and decreasing the workload of processing each one.”
18. The survey methodology presented in form DI-4010 includes a specific description of:
The respondent universe,
The sampling plan and all sampling procedures, including how respondents will be selected,
How the instrument will be administered,
Expected response rate and confidence levels,
Strategies for dealing with potential non-response bias,
A description of any pre-testing and peer review of the methods and/or the instrument is highly recommended,
The burden hours reported in the Justification include the number of burden hours associated with the initial contact of all
individuals in the sample (i.e., including refusals), if applicable, and the number of burden hours associated with individuals
expected to complete the survey instrument, and
The package is properly formatted (using MS Word) and submitted to the Office of Policy Analysis (through the Bureau/Office
Information Collection Clearance Officer).
19. The approval package includes:
A completed and signed Form DI-4010, Generic Clearance for Customer Satisfaction Surveys.
A copy of the survey instrument.
Other supporting materials, such as:
• Cover letters to accompany mail-back questionnaires,
• Introductory scripts for initial contact of respondents,
• Necessary Paperwork Reduction Act and Estimated Burden compliance language, and/or
• Follow-up letters/reminders sent to respondents.
20. Checklist for Submitting a Request to Use DOI Programmatic Clearance for Customer Satisfaction Surveys
All questions in the survey instrument are within the scope of one of the DOI Programmatic Clearance for Customer
Satisfaction Surveys topic areas.
A qualified statistician has reviewed and approved your request (see question 21A).
Your Bureau/Office Information Collection Clearance Officer receives your package for review/approval at least 75 days
prior to the first day the PI wishes to administer the survey to the public.
21. Required Certifications for Submission Under OMB Control Number 1040-0001
Certification is required to submit a collection of information for approval under the DOI Programmatic Clearance for Customer
Satisfaction Surveys. If the collection does not satisfy the requirements of the Programmatic Clearance, you should follow the
regular PRA clearance procedures described in 5 CFR 1320.
21A. Bureau/Office Statistician
Signature
Date
Recommend
Not Recommended
21B. Bureau/Office Program or Subgroup
Bureau/Office Point-of-Contact
Title (Please be specific)
Signature
Date
FOR PROGRAM USE ONLY
Required certifications: The information collection requested by this submission meets the requirements of OMB Control No. 1040-0001
Bureau/Office ICCO
Recommend
Signature
Date
Signature
Date
Not Recommended
DOI PRA Program Lead
Approved
Date
Not Recommended
DOI Office of Policy Analysis
Recommend
Signature
DOI Tracking No.
Not Approved
Page 7 of 9
DI-4010 (Rev. 03/2021)
U.S. Department of the Interior
OMB Control. No. 1040-0001
Expiration Date ##/##/####
Instructions for Completing Form DI-4010,
Justification for Submission Under the
“DOI Programmatic Clearance for Customer Satisfaction Surveys”
OMB Control Number 1040-0001
1.
Bureau/Office: Insert the name of the bureau/office conducting the survey.
2.
Date Submitted: Date you submit the package to the Bureau/Office Information Collection Clearance Officer (ICCO) for review.
3.
Survey Title: Insert title for the proposed survey.
4.
Abstract: Summarize the proposed study with an abstract not to exceed 150 words.
5.
Bureau/Office Point of Contact Information: Complete the bureau/office contact information. PPA will communicate with the
point of contact listed here throughout the entire approval process.
6.
Principal Investigator (PI) Conducting the Survey: Complete information about the PI who will be conducting the survey, if
different from Point of Contact listed in #4. Otherwise note: Same as #4.
7.
Name of Program Office Conducting Survey: Provide the name of the bureau program, office, or organizational unit conducting
the survey.
8.
Description of Customers and Services Provided: Provide a brief description of the customers you will survey, the services
provided by the program conducting the survey, and customers receive these services.
9.
Survey Dates: List the time-period in which you will conduct the survey, including specific starting and ending dates. The starting
date should be at least 75 days after the date you submit the package to your bureau/office Information Collection Clearance
Officer (ICCO).
10. Type of Information Collection Instrument: Check the type(s) of information collection instrument(s) you will use. If other,
please explain.
11. Survey Development: Explain how the survey was developed. With whom did you consult during the development of the survey
on content? On statistics? Did you pretest the survey? What actions did you take to improve the survey? What suggestions did
you receive for improving the survey? Which of the six topic areas will the collection address? (Note: A description of any pretesting and peer review of the methods and/or instrument is highly recommended.)
12. Survey Methodology: Explain how you will conduct the survey. Provide a description of the survey methodology including:
•
Question 12A – The respondent universe,
•
Question 12B – The sampling plan and all sampling procedures;
•
Question 12C – How the instrument will be administered;
•
Question 12D – Expected response rate and confidence levels;
•
Question 12E – Strategies for dealing with potential non-response bias; and,
•
Question 12A – Description of any pre-testing and peer review of the methods and/or instrument (recommended, but not
required).
Note: Web-based surveys are not an acceptable method of sampling a broad population. Web-based surveys must be limited to
services provided by the web site.
13. Burden Hours Calculations: Provide an estimated total of the following for each category – initial contact and completion of
survey instrument:
•
Number of annual respondents – Enter the number of unique respondents who will complete the information collection;
•
Number of responses per respondent – Enter the total number of responses per unique respondent;
•
Total annual responses – Enter the number of unique respondents multiplied by the total number of responses each;
•
Time per response – Estimate the time to complete the initial contact and the time to complete the survey instrument (in
minutes), and
•
Total burden hours –The total burden hours should account for the amount of time required to instruct the respondents in
completing the survey, and the amount of time required for the respondent to complete the survey.
14. Federal Enterprise Architecture (FEA) Business Reference Model: Using the drop-down menus provided, select ONE “Line of
Business” and ONE corresponding Subfunction that most accurately describes your information collection.
15. Reporting Plan: Provide a brief description of the reporting plan for the data you will collect.
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DI-4010 (Rev. 03/2021)
U.S. Department of the Interior
OMB Control. No. 1040-0001
Expiration Date ##/##/####
16. Justification, Purpose and Use: For questions 16A through 16F, provide a brief justification for the survey, its purpose, goals,
and utility to managers. Specifically, describe how you will tabulate the data and what the statistical techniques you will use to
generalize the results to the entire customer population. Describe how you will use the data from the survey. Describe how you
will acknowledge any limitations related to the data, particularly in cases where we obtain a lower than anticipated response rate.
Note whether you intend the survey to measure a Government Performance and Results Act (GPRA) performance measure.
17. Federal Cost: Provide the cost estimate for the Federal government to administer the information collection, along with a
description of how you calculated the cost estimate (sample response provided). Contact your bureau/office ICCO for more
information or for assistance.
18. Survey Methodology Checklist: Carefully review each item and check each box to indicate your submission provides
the required description of each item.
19. Checklist for Submitting a Request to Use DOI Programmatic Clearance for Customer Satisfaction Surveys: Carefully
review each item and check each box to indicate your understanding and concurrence of each requirement.
20. Approval Package Content: Carefully review each item and check each box to indicate your package contains each of the
requirement elements listed.
NOTE: Your survey instrument document must show the OMB Control Number 1040-0001 and Expiration Date ##/##/###, and it
MUST include the following Statements somewhere on the instrument document (preferably at the bottom of page 1 or at the end
of the document):
Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act
(44 U.S.C. 3501) to [insert brief justification for collection of information]. Your response is voluntary and results we
will not share them publicly. We may not conduct or sponsor and you are not required to respond to a collection of
information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey
and assigned OMB Control Number 1040-0001.
Estimated Burden Statement: We estimate the [insert type of instrument] will take you ## minutes to complete,
including time to read instructions, gather information, and complete and submit your response. You may submit
comments on any aspect of this information collection to the Information Collection Clearance Officer, [Insert
Bureau/Office], [Insert mailing address].
21. Required Certifications: Completion of all information in this section is required before forwarding your approval
package to your bureau/office ICCO for review and processing.
Question 21A – Ensure the bureau/office statistician reviewing your information collection certifies the request satisfies
the requirements of the DOI Programmatic Clearance for Customer Satisfaction Surveys under OMB Control No. 10400001.
Question 21B – Ensure the requestor provides the requested contact information needed by the bureau/office and/or
Departmental ICCO to resolve questions or concerns.
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| File Type | application/pdf |
| File Modified | 2021-03-08 |
| File Created | 2021-03-08 |