FWS Form 3-1240, "Information Collection Request Form"

FWS Form 3-2140 (Rev. 06/2020)

U.S. Department of the Interior

INFORMATION COLLECTION REQUEST FORM

Programmatic Clearance for

U.S. Fish and Wildlife Service Social Science Research

Internal Use Only
Tracking Number:	Click here to enter text.	Date Submitted:	Click here to enter a date.

Instructions: Please answer all questions completely and sign the certification statement. Individual item instructions can be found below the form.

Principal Investigator
Name:	Click here to enter text.
Title:	Click here to enter text.
Affiliation or Office:	Click here to enter text.
Address:	Click here to enter text.
Phone Number:	Click here to enter text.
Email:	Click here to enter text.

Sponsoring Office Point of Contact (If different from Principal Investigator)
Name:	Click here to enter text.
Title:	Click here to enter text.
Affiliation or Office:	Click here to enter text.
Address:	Click here to enter text.
Phone Number:	Click here to enter text.
Email:	Click here to enter text.

3. Project Title

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4. Abstract (maximum 150 words)

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Screening Questions
Will this collection or any of its questions… (Check next to the question if the answer is ‘yes.’)
☐	Address a topic that would be considered controversial (i.e., might attract attention to significant, sensitive, or political issues)?
☐	Be used to substantially inform or influence policy decisions?
☐	Potentially raise issues of concern to other federal agencies?
Please explain any ‘yes’ responses.

6. Project Justification

Explain the circumstances that make the collection of information necessary. Please consider the following questions when answering this section: What is the issue or problem (why are you seeking an information collection)? What social science data/information will help you address this issue? How will the information be used and integrated into the decision process? What management actions would be influenced by the information collected?

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Project Information
Where will the information collection take place (e.g., refuge, community, region)? Click here to enter text.
Collection Period		Start Date: Click here to enter a date.		End Date: Click here to enter a date.
Information Collection Method(s) (Check all that apply)
	☐ On-site surveys	☐ Telephone surveys	☐ Interviews
	☐ Mail-back surveys	☐ Web-based surveys	☐ Focus group(s)
	☐ Other (please describe): Click here to enter text.
Will an electronic device (e.g., tablet or other hand-held device) be used to collect information? ☐ No ☐ Yes – What type of device? Click here to enter text.
Will personally identifiable information (PII) be collected? ☐ No ☐ Yes – If PII will be collected, briefly describe the purpose for doing so. Click here to enter text.
Will an incentive (e.g., money or reimbursement of expenses, token of appreciation) be provided to participants? ☐ No ☐ Yes – Please explain: Click here to enter text.

Topic Areas Covered in this Information Collection (Check all that apply)*
☐	Respondent characteristics	☐	Environmental & Ecological Awareness: Knowledge, Beliefs, Values and Attitudes
☐	Communication preferences	☐	Perceptions of and Preferences for Resources Management
☐	Trip Planning and Logistics	☐	Visitor Expenditures and Economic Inputs
☐	Trip Activities and Experience	☐	Environmental Education/Program Evaluation
☐	Opinions about Facilities, Services and Recreational Opportunities	☐	Public Participation, Outreach and Partners Partnerships

* For each question in your survey (or interview guide), please indicate the Topic Area and the unique question identifier from the Suite. For any questions that are not taken from the Question Suite, please indicate “NEW” in the table.

9. Research Design

1. Population of Interest. Describe the potential respondents that make up the population, target audience or respondent universe (including numerical estimates). This is the group of people from which you will draw your sample (if applicable).

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2. Sampling Strategy. Describe any sampling or other respondent selection method to be used (e.g., sample of convenience, random sampling, quota sampling).

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3. Information Collection Implementation. For each of the methods you checked under “Proposed Information Collection Method” above, describe how it will be implemented (i.e., how will your surveys be administered or focus groups conducted?).

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4. Expected Response Rate/Confidence Levels. Use the table below to report expected response rate(s) and confidence level(s). If collecting information from more than one population, please include response rates and confidence levels for each population separately.

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Population or Audience	Number of Initial Contacts	Expected Number of Responses	Expected Response Rate	Margin of Error +/- %	Confidence Level
Click here to enter text.	kh	     
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Total	0	0	0%

5. Non-response Bias Detection and Correction. Describe the strategies you will employ to identify and deal with the potential biases in your data attributable to a difference in characteristics and/or opinions of those who participated in your collection and those who did not.

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6. Pre-testing/Peer Review. Describe any pre-testing and/or peer review of the methods and/or instrument. Please include names of peer reviewers.

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10. Estimate of Response Burden

Use the table below to estimate the total response burden.

1. Fill in the total number of initial contacts and the total number of expected respondents.

2. Fill in the estimated time to complete the initial contact and the survey instrument (in minutes).

3. Multiply total number of initial contacts by initial contact time.

4. Multiply total number of expected responses by time to complete the survey instrument.

5. Add the two estimated times to arrive at the total burden.

Total number of initial contacts		x	Initial contact time (in minutes)		=	Total contact time
Total number of expected responses		x	Estimated time to complete (in minutes)		=	Total response time
						Total response burden

11. Analysis & Reporting

1. Please describe any statistical analyses you plan to conduct.

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2. Reporting Plan. Please indicate in what ways you will report on the results of your collection and how you plan to disseminate results.

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Certification Statement
By submitting this document, 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. Information gathered will not be used for the purpose of substantially informing influential policy decisions. Data storage and management protocols are sufficient to protect PII and meet the guidelines set forth in the 2013 FWS Privacy Guidelines.
Name: Enter Full Name.	Date: Select Date.

Instructions for Completing the
Information Collection Request Form

1. Principal Investigator (PI). Fill in contact information for the person conducting the study. The Information Collection Request Coordinator will communicate with the PI listed here throughout the entire process. PIs may be refuge managers, researchers from universities, and individuals from organizations cooperating with the Service, among others. For studies in which graduate students are taking a lead role, the faculty advisor or sponsoring office liaison must be listed as the PI and not the student.

2. Sponsoring Office Point of Contact (if different from Principal Investigator). Fill in the U.S. Fish & Wildlife Service program or refuge point of contact information. List only one liaison for the purposes of the review process, even if the study is being conducted across multiple sites, regions, or programs. The sponsoring office will be responsible for reviewing the final submission for relevancy and appropriateness before a final review will be performed by the Information Collection Request Coordinator.

3. Project Title. Insert a title for the proposed study.

4. Abstract. Provide a summary of the need for the proposed study, how the information will be used, and a description of the respondents. Please limit to 150 words.

5. Project Justification. Provide an explanation of the need/justification for the study. Describe the purpose, goals, and utility to the Service.

6. Screening Questions.

7. Project Information. Provide explanations for each of the following aspects of the project:

   1. Study Location. List the location(s) in which the data collection will be conducted or for which the data is being collected.

   2. Collection Period. List the time period in which the IC will be conducted, including approximate starting and ending dates. The starting date should be at least 60 days after the submission date.

   3. Information Collection Method(s). Check the type(s) of information collection instrument(s) that will be used. If “other,” please explain.

   4. Provide details about the use of electronic devices that may be used to collect information.

8. Topic Areas Covered in this Information Collection. Which of the five topic areas from the Suite of Questions will be addressed in your IC?

9. Research Design. Provide explanations for each of the following aspects of the information collection:

1. Population of Interest. Provide a brief description of the population/potential respondents from whom the information will be collected (e.g., adult visitors to Rocky Mountain Arsenal NWR);

2. Sampling Strategy. Describe the sampling plan and all sampling procedures, including how individual respondents will be selected and a justification for the planned sample size;

3. Non-response Bias Detection and Correction. Describe how the instrument will be administered in the field, including follow-up procedures to increase response rates;

4. Expected Response Rate/Confidence Levels. Estimate the expected response rate and confidence levels, including a justification of the anticipated response rate by citing specific studies similar to the proposed one and their response rates;

5. a plan for analyzing and reporting the implications of any non-response bias detected (include a copy of your survey log, if applicable);

6. Pre-testing and Peer Review. A description of any pre-testing and peer review of the methods and/or instrument. With whom did you consult during the development on content? Did you pretest the data collection instrument? Who were the social science and/or statistical experts who reviewed the instruments? How did you address any concerns raised or improvements suggested?

10. Response Burden. Burden is defined as the total time, effort, or financial resources expended by persons to generate, maintain, retain, or disclose or provide information to or for a federal agency. This includes the initial contact, amount of time required to review instructions, and the amount of time required for the respondent to complete the survey (or other data collection mechanism). Burden on non-respondents (such as initial contact interviews with individuals declining to participate) should be included in this total.

To estimate the total number of burden hours:

1. Estimate the total number of initial contacts.

2. Estimate the total number of expected respondents.

3. Estimate the amount of time to complete the initial contact (in minutes).

4. Estimate the amount of time to complete the survey instrument (in minutes).

5. Multiply the total number of initial contacts by the initial contact time.

6. Multiply the total number of expected responses by the estimated time to complete the survey instrument.

7. Add the two estimated times to arrive at the total burden.

11. Analysis & Reporting Plan. Provide a brief description of the reporting plan for the data being collected. This might include a final technical report, a briefing for managers, a peer-reviewed journal article, etc.

12. Certification Statement. After completing the form, enter the name of the person who certifies that the information collection meets the requirements of the programmatic clearance (OMB control number XXXX- XXXX).