Goddard fast track form

Request for Approval under NASA’s “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 2700-0153)

1. Title of information collection	Goddard on the Green Post Event Survey
2. Purpose	NASA Goddard Space Flight Center hosted its first centerwide employee event on the “Goddard Mall” in several years. This survey will enable us to collect necessary feedback from our workforce to enhance future events of this nature.
3. Description of respondents	Goddard employees (civil servants, contractors, interns) that participated in the festivities

4. Type of collection (check one)

Customer comment card/complaint form	X Customer satisfaction survey
Usability testing (e.g., website, software)	Small discussion group
Focus group	Other:      

5. Personally identifiable information

Will PII be collected?	Yes	X 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

6. Gifts or payments

Is an incentive provided to participants? (e.g., money, reimbursement of expenses, token of appreciation)

Yes

X No

7. Burden time per response (best estimate)

Category of respondent	Number of respondents, per year	Participation time (list in minutes)	Total burden time (in hours)
Attendees	2000	5 min	167 hrs

8. Federal cost (If any, typically listed as the total burden time in hours x $30 = federal cost. This includes: printing, shipping, IT, contracting, and does not include salaries)

No extra costs

9. The selection of your targeted respondents

Do you have a customer list or similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe?	X Yes	No
If yes, please provide a description of both below (attach a sampling plan if available). List of potential respondents will be Goddard employees. We will email Goddard’s workforce via our distribution listserv for identity information.
If no, please provide a description of how you plan to identify your potential group of respondents and how you will select them.      

10. Administration of the instrument (check all that apply)

X Web-based or email (SurveyMonkey, MS Forms, etc)	Telephone		In person	Snail mail
Other, please list:      
Will interviewers or facilitators be used?		Yes		X No
Please provide the URL: https://forms.gle/EYZ7UCwUa4w7F5cx8

11. Certification. Please certify the following to be true

X The collection is voluntary.

X The collection is low-burden for respondents and low-cost for the Federal Government.

X The collection is non-controversial and does not raise issues of concern to other federal agencies.

X The results are not intended to be disseminated to the public.

X Information gathered will not be used for the purpose of substantially informing influential policy decisions.

X 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 of Gov’t Civil Servant SME: JaDonna Berger

Center, division, & program: GSFC, Code 120, Office of Communications (Public Engagement)  

12. Besides completing this fast-track form, return the following to the PRA Team:

Please provide as Word files:

• Screenshots of your collection instrument

• Text of your collection instrument

• Include any transmittal email, or other mechanisms, that you plan to inform recipients with

Instructions for completing the fast-track form

1. 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 Annual Meeting).

2. Purpose: Provide a 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.

3. Description of respondents: Provide a description of the targeted group or 2 groups for this collection. These groups must have experience with the program.

4. Type of collection: If you are requesting approval of other instruments under the generic IC, you must complete a form for each instrument.

5. 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.

6. Gifts or payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

7. 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) US federal government. Only one type of respondent can be selected per row.

Number of respondents: Provide an estimated number of those who would respond.

Participation time: Provide an estimate of the amount of time (in minutes) required for a respondent to participate (e.g., how much time will it take to fill out the survey or participate in a focus group). Provide the annual burden hours. Multiply the number of respondents and the participation time then divide by 60.

8. Federal cost: Provide an estimate of the annual cost to the Federal government.

9. 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 you answered yes to the first question, please provide the sampling plan as an attachment.

10. 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 list the URL here for an online survey.

11. Certification: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or be disapproved.

12. Submit all instruments and scripts with the request.

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