CERTIFICATION:
I
certify the following to be true:
The
collection is voluntary.
The
collection is low-burden for respondents and low-cost for the
Federal Government.
The
collection is non-controversial and does not raise issues
of concern to other federal agencies.
The
results are not intended to be disseminated to the
public.
Information
gathered will not be used for the purpose of substantially
informing influential policy decisions.
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:
To
assist review, please provide answers to the following question:
Personally
Identifiable Information:
Is
personally identifiable information (PII) collected?
Yes No
If
“Yes”, will any information that is collected be
included in records that are subject to the Privacy Act of 1974?
Yes No
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 Respondents:
Individuals or Households
Private Sector
State, Local, or Tribal Governments
Federal Government
Category of Respondent
|
No. of Respondents
|
Participation Time
|
Burden
|
Companies, Other
Stakeholders From the Above Categories
|
300
|
5 min (0.083 hours)
|
25 hours
|
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
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
How
will you collect the information? (Check all that apply)
Web-based or other forms of Social Media
Telephone
In-person
Mail
Other (Explain)
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 the
Collection of Routine Customer Feedback”
TITLE
OF INFORMATION COLLECTION: Provide the name of the collection
that is the subject of the request.
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 (in minutes)
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
Respondents and the Participation Time then 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.