Generic Testing Clearance Summary Template under EIA-882T

Request for Approval under the “Generic Clearance for Questionnaire Testing and Research” (OMB Control Number: 1905-0186)

TITLE OF INFORMATION COLLECTION:

PURPOSE:

DESCRIPTION OF RESPONDENTS:

TYPE OF COLLECTION: (Check one)

[ ] Field Testing [ ] Cognitive Interviews

[ ] Usability Testing [ ] Focus Groups

[ ] Pilot Surveys [ ] Other: ______________________

[ ] Respondent Debriefings

CERTIFICATION:

I certify the following to be true regarding the proposed collection of information:

1. It is necessary for the proper performance of agency functions.

2. It avoids unnecessary duplication.

3. It reduces burden on small entities.

4. It uses plain, coherent, and unambiguous language that is understandable to respondents.

5. Its implementation will be consistent and compatible with current reporting and recordkeeping practices.

6. It indicates the retention periods for recordkeeping requirements.

7. It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

   1. Why the information is being collected;

   2. Use of information;

   3. Burden estimate;

   4. Nature of response (voluntary, required for a benefit, or mandatory);

   5. Nature and extent of confidentiality; and

   6. Need to display currently valid OMB control number

8. It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

9. It uses effective and efficient statistical survey methodology (if applicable).

10. It makes appropriate use of information technology.

Name: __________________________________________

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

Personally Identifiable Information:

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

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

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Totals

ESTIMATE OF RESPONDENT BURDEN HOURS AND COST – The burden to respondents is xx hours and the cost to the respondents is estimated to be ($80.14 * xx) = $xxxx.00.

FEDERAL COST: The estimated annual cost to the Federal government is:

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

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? [ ] 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?

Administration of the Instrument

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

2. Will interviewers or facilitators be used? [ ] Yes [ ] 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 Questionnaire Testing and Research”

(OMB Control Number: 1905-0186)

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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