Onsite Survey (post-rmp) v03.29.22 OMB

OMB Control Number: 1004-xxxx

Expiration Date: xx-xx-20xx

Bureau of Land Management

Planning and Management for Recreation

DRAFT On-Site Survey (Interactive interview with Research Assistant)

ID#:_______________

Dear Public Lands Visitor:

We are conducting this survey to learn more about visitors to Bureau of Land Management public lands in (state), so that public land managers can improve their service to you. You are one of a small number of people randomly chosen for this survey, so your opinions are important to us. Although we would greatly appreciate your help, you are free to decline this interview. Your responses will be considered your consent to participate. All the information will be used for our statistical purposes. Would you be willing to take one minute to answer a few short questions about your visit today? (read by interviewer)

Interviewer: Before I begin would you like to see the Office of Management and Budget Privacy Act and Paperwork Reduction Act statement? (If yes, hand the card with the statement.)

1. How many people are in your group today, including yourself? ________ (enter number)

2. As shown on the included map, we have divided the (name) into (#)recreation zones. Please check the boxes for all of the zones that you plan/have visited during this trip:

 - Zone 1 (name)  - Zone 5 (name)

 - Zone 2 (name)  - Zone 6 (name)

 - Zone 3 (name)  - Zone 7 (name)

 - Zone 4 (name)  - Zone 8 (name)

3. If you plan to visit more than one zone, which zone do you consider to be your primary destination? (from map provided)

Zone # ______

4. What is your zip code (or country if you are not a U.S. resident)? ____________________

Your Opinions Are Important to us!

Would you be willing to take home and complete a more detailed mail-back survey or complete the same survey on the internet? The results will help public land managers to provide high quality recreation opportunities. Again, your participation in this study is completely voluntary. Your name, address and phone number (or name and email) will only be used to contact you for this study and will not be shared. We will send you a reminder in about 10 days. (Are you willing to take a mail survey home and fill it out or complete an internet survey?) Hand the clipboard to respondent to fill-in name and address (or name and email address), then provide with the mail survey, map and pre-paid postage envelope to take home.

Name (first and last) _____________________________________________

Street Address _____________________________________________

City ________________________ State __________ Zip Code__________

OR

Name (first and last) _____________________________________________

Email Address _____________________________________________

Thank you very much!

NOTICES

PRIVACY NOTICE: The Bureau of Land Management (BLM) is authorized by 43 U.S.C. 1711 and 1712 to collect this information. This information will be used by BLM managers to better understand recreational visits to public lands managed by the BLM. Your response to this request is voluntary and completely anonymous. Your name will never be associated with your answers, and all contact information will be destroyed when the information collection is concluded. No action may be taken against you for refusing to supply the information requested. DOI will not share this information unless authorized or as required by Federal law for security or law enforcement purposes.

PAPERWORK REDUCTION ACT STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number and expiration date. The OMB control number for this survey is 1004-XXXX (expiration date: xx/xx/20xx).

BURDEN ESTIMATE STATEMENT: Public reporting for this form is estimated to average 1 minute per response. Please direct comments regarding the burden estimate or any other aspect of this information collection to: U.S. Department of the Interior, Bureau of Land Management, Bureau Information Collection Clearance Officer (WO-630), 1849 C St., N.W., Room 2134LM, Washington, DC 20240.

This information will be used by public land managers to better serve the public. Your response to this request is voluntary. No action may be taken against you for refusing to supply the information requested. Your name is requested for follow-up mailing purposes only. When analysis of the questionnaire is completed, all name and address files will be destroyed.

Office Use Only: Online Code: _______________

Date_________ Time_______ Location (zone) _______ Staff Initials ________