New NASA Fast Track Template

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	     
2. Purpose	     
3. Description of respondents	     

4. Type of collection (check one)

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

5. Personally identifiable information

Will PII be 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

6. Gifts or payments

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

Yes

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)
     	     	     	     

* Estimated number received, not sent out

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)

     

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?	Yes	No
If yes, please provide a description of both below (attach a sampling plan if available).      
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)

Web-based or email (SurveyMonkey, MS Forms, etc)	Telephone	In person	Snail mail
Other, please list:      
Will interviewers or facilitators be used?		Yes	No
Please provide the URL:      
Will the information collection be secure on a NASA approved system?		Yes	Other, explain

11. Certification. Please 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 of Gov’t Civil Servant SME:      

Center, division, & program:      

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

Please provide as Word files:

• Completed fast-track form

• 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: Describe a purpose for 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 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.

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 per row.

Number of respondents: Provide an estimated number of those who will 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. Note that online surveys must be collected or stored on an agency approved system (e.g.: NASA’s Office apps)

11. Certification: Please read and check off the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or be disapproved. This form must be approved by a NASA Civil Servant.

2