Request for Approval

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 1405-0193)
Expiration Date: 9-30-2021

TITLE OF INFORMATION COLLECTION: J-1 Teacher Check-In
·
PURPOSE: The primary purpose of this survey will be used to check in on teachers on the BridgeUSA
program (formerly the Exchange Visitor Program) to ensure their health, safety, and welfare. The survey
also will ask about their exchange experience. Answers will be collected electronically through the
Qualtrics program. Responses will be anonymous, and taking the survey is voluntary. The survey has 34
questions and is attached. Respondents will only give their name (optional) if they wish our office to
follow up with them after they have taken the survey.

Public reporting burden for this collection of information is estimated to average 15 minutes per
response, including time required for searching existing data sources, gathering the necessary
documentation, providing the information and/or documents required, and reviewing the final
collection. You do not have to supply this information unless this collection displays a currently
valid OMB control number. If you have comments on the accuracy of this burden estimate
and/or recommendations for reducing it, please send them to: [email protected]
DESCRIPTION OF RESPONDENTS: We plan to send the survey to around 200 Teachers on
the BridgeUSA program (Exchange Visitor Program) who were on program in the 2020-2021
program year.
TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[ x] Customer Satisfaction Survey
[ ] Small Discussion 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:__Jennifer Nupp_________________________________________
To assist review, please provide answers to the following question:
Personally Identifiable Information:

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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
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
Participation
Burden
Respondents Time
200
.25 of an hour
50
per participant minutes
(15 minutes
per participant)

Teacher exchange visitors

Totals

200

.25 of an hour
per participant

50
minutes

FEDERAL COST: The estimated annual cost to the Federal government is $220
There is no cost to identify the respondents. The list of respondents is in our participant
database, so there is no cost associated with identifying those who would take the survey. The
200 respondents represent all participants in this exchange category for the time-period
indicated. The only cost would be staff time to download responses from Qualtrics and review
the results. We anticipate that one GS-9 staff member at an hourly wage of $22 would take 10
hours to review and analyze the results.
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions: n/a
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?
[ x] Yes
[ ] 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?
Respondents will be all teachers for the 2020-2021 school year, as contained in our database. All
participants in this category will be surveyed, so there will not be sampling.
Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[ x ] Web-based or other forms of Social Media (Qualtics survey program)

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[
[
[
[

] Telephone
] In-person
] Mail
] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [x ] No
Please make sure that all instruments, instructions, and scripts are submitted with the
request.

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:

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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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