Template

Request for Approval under the “Generic Clearance for Improving
Customer Experience: OMB Circular A-11, Section 280
Implementation”
(OMB Control Number: 3145-XXXX)
TITLE OF INFORMATION COLLECTION:

XXX

PURPOSE OF COLLECTION:
What are you hoping to learn / improve? How do you plan to use
what you learn? Are there artifacts (user personas, journey
maps, digital roadmaps, summary of customer insights to inform
service improvements, performance dashboards) the data from this
collection will feed?
XXX
TYPE OF ACTIVITY: (Check one)
[
[
[

] Customer Research (Interview, Focus Groups)
] Customer Feedback Survey
] User Testing

ACTIVITY DETAILS
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. Who will you collect the information from?
Explain who will be interviewed and why the group is appropriate
for the Federal program / service to connect with. Please
provide a description of how you plan to identify your potential
group of respondents and if only a sample will be solicited for
feedback, how you will select them(e.g., anyone who provided an
email address to a call center rep, a representative sample of
Veterans who received outpatient services in May 2019, do you
have a list of customers to reach out to (e.g., a CRM database
that has the contact information, intercept interviews at a
particular field office?)
XXX
3. How will you ask a respondent to provide this information?
(e.g., after an application is submitted online, the final
screen will present the opportunity to provide feedback by
presenting a link to a feedback form / an actual feedback form)
XXX
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4. What will the activity look like?
Describe the information collection activity – e.g. what happens
when a person agrees to participate? Will facilitators or
interviewers be used? What’s the format of the interview/focus
group? If a survey, describe the overall survey
layout/length/other details? If User Testing, what actions will
you observe / how will you have respondents interact with a
product you need feedback on?
XXX
5. Please provide your question list.
Paste here the questions or prompts presented to participants in
your activity. If you have an interview / facilitator guide,
that can be attached to the submission and referenced here.
Please make sure that all instruments, instructions, and scripts
are submitted with the request.
XXX
6. When will the activity happen?
Describe the time frame or number of events that will occur
(e.g., We will conduct focus groups on May 13,14,15, We plan
to conduct customer intercept interviews over the course of
the Summer at the field offices identified in response to #2
based on scheduling logistics concluding by Sept. 10th, or
“This survey will remain on our website in alignment with the
timing of the overall clearance.”)
XXX
7. Is an incentive (e.g., money or reimbursement of expenses,
token of appreciation) provided to participants?
[ ] Yes [ ] No
If Yes, describe:
XXX
BURDEN HOURS
Category of Respondent

No. of
Respondents

Totals

CERTIFICATION:
I certify the following to be true:
2

Participation
Time

Burden
Hours

1. The collections are voluntary;
2. The collections are low-burden for respondents (based on
considerations of total burden hours or burden-hours per
respondent) and are low-cost for both the respondents and the
Federal Government;
3. The collections are non-controversial and do not raise issues
of concern to other Federal agencies;
4. Any 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 near future;
5. Personally identifiable information (PII) is collected only to
the extent necessary and is not retained;
6. Information gathered is intended to be used for general
service improvement and program management purposes; and,
7. Information gathered will only be shared publically in the
manner described in the umbrella clearance of this control
number.
Name:________________________________________________
All instruments used to collect information must include:
OMB Control No. 3134-XXXX
Expiration Date: XX/XX/XXXX

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HELP SHEET
(OMB Control Number: 3145-XXXX)
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.
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: 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.
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.

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