Ds-4183

U.S. Department of State

REQUEST FOR APPROVAL UNDER THE "GENERIC CLEARANCE
FOR THE COLLECTION OF ROUTINE CUSTOMER FEEDBACK"
OMB CONTROL NUMBER: 1405-0193
Title of Information Collection
Purpose

The Department of State Under Secretary for Public Diplomacy’s Office of Policy Planning and Public Resources, Research and
Evaluation Unit (RPPR/REU) is conducting an evaluation of the U.S. Gilman Scholar UN Study Tour in Rome that will examine
the extent to which participation in a study tour contributes to increased awareness and knowledge of UN food and agriculture
agencies, increased knowledge of career opportunities and the UN application process, increased interest in working at UN food and
agriculture agencies, and connections with UN experts, HR professionals, and fellow Gilman scholars. The collection of responses
from study tour participants will assist in the REU's ability to assess the degree to which the program achieved these above stated
outcomes.
In efforts to limit the burden to respondents the REU will work in collaboration with the grantee responsible for the study abroad
program to add only the minimum number of necessary questions and incorporate the questionnaire delivery into existing program
elements. The REU has finalized five questions to be sent to program participants. Additionally, the REU will conduct follow up
focus groups to assist in the information gathering needed to better understand participants experiences during the Gilman scholar
study tour. The focus groups will be voluntary, confidential, and the time will be minimized as much as possible.
Description of Respondents

The respondents to the survey and focus groups will be participants of the Gilman Scholars Study Abroad Tour in Rome, managed
by the Public Diplomacy Section of the U.S. Mission to the United Nations in Rome. These individuals are U.S. citizens currently
enrolled in undergraduate programs at U.S. universities. A total of 14 participants of the program will be invited to voluntarily
participate in the survey. R/PPR/REU will follow all procedures stipulated under the Privacy Act 1974, as amended.
Participation in the survey and focus groups is entirely at-will and can be declined at any time. Personal identifying information will
not be collected as a result of this survey or the interview, however that information will be made available to the REU as a result of
their participation in the program. This information will not be stored or associated with the focus group results and will only be
used to track completion.

Type of Collection: (Check one)
Customer Comment Card/Complaint Form

Customer Satisfaction Survey

Usability Testing (e.g., Web site or Software)

Small Discussion Group

Focus Group

Other

Certification
I certify the following to be true:
1. The collection is voluntary.
2. The collection is low-burden for respondents and low-cost for the Federal government.
3. The collection is non-controversial and does not raise issues of concern to other Federal agencies.
4. The results are not intended to be disseminated to the public.
5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.
6. 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 (Last, First, MI)

Amelia
Signature

DS-4183
07-2019

Title

Arsenault

Director, PD Research and Evaluation

signed by Amelia H Arsenault
Amelia H Arsenault Digitally
Date: 2024.02.27 11:04:04 -05'00'

Date (mm-dd-yyyy)

Page 1 of 2

TO ASSIST REVIEW, PLEASE PROVIDE ANSWERS TO THE FOLLOWING QUESTIONS.
Personally Identifiable Information
1. Is personally identifiable information (PII) collected?
a. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974?
2. If Applicable, has a System of Records Notice been published?

Yes

No

Yes

No

Yes

No

Yes

No

Gifts or Payments
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?
BURDEN HOURS
Category of Respondent

Number of Respondents Participation Time (Minutes)

Individuals or Households

14

Totals

50

14

Burden Hours

12

12

FEDERAL COST
The estimated annual cost to the Federal government is

$0.00

IF YOU ARE CONDUCTING A FOCUS GROUP, SURVEY, OR PLAN TO EMPLOY
STATISTICAL METHODS, 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.

The participant list for the program will be used as the sample frame for both the survey and focus groups.

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?

DS-4183

Yes

No

PLEASE MAKE SURE THAT ALL INSTRUMENTS, INSTRUCTIONS, AND SCRIPTS ARE SUBMITTED WITH THE REQUEST.
Page 2 of 2

U.S. Department of State

REQUEST FOR APPROVAL UNDER THE "GENERIC CLEARANCE
FOR THE COLLECTION OF ROUTINE CUSTOMER FEEDBACK"
OMB CONTROL NUMBER: 1405-0193
INSTRUCTIONS
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.
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.
Number 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 by the participation time, and 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.
Please make sure that all instruments, instructions, and scripts are submitted with the request.

DS-4183
07-2019

Instruction Page 1 of 1