Qualtrics Platform Survey for the Bureau of Educational and Cultural Affairs (ECA)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DS-7101 Qualtrics Platform Survey	Form and Instruction	New	Available
Form DS-7101 Qualtrics Platform Survey	Form and Instruction	New	Repair queued
Qualtrics OMB PRA Legal Authorities.docx	Supplementary Document	Uploaded 2024-10-31	Repair queued
Qualtrics OMB PRA Legal Authorities.docx	Supplementary Document	Uploaded 2024-10-31	Available
Qualtrics OMB Supporting Statement (30-day)_AK.docx	Supporting Statement A	Uploaded 2024-10-31	Available
Qualtrics OMB Supporting Statement (30-day)_AK.docx	Supporting Statement A	Uploaded 2024-10-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
272028	Qualtrics Platform Survey	Form and Instruction	New	Qualtrics Platform Survey
272028	Qualtrics Platform Survey	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202410-1405-003
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Qualtrics Platform Survey for the Bureau of Educational and Cultural Affairs (ECA)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted	Conclusion Date: 04/29/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/31/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Department of State’s Bureau of Educational and Cultural Affairs (ECA) regularly monitors and evaluates its programs through the collection of data of program performance in order to enable ECA staff to assess the effectiveness of its programs and to modify and plan future programs. The Qualtrics survey platform will create a standardized method for survey distribution, data collection, and data visualization.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 12470	08/06/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 12575	10/31/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Qualtrics Platform Survey	DS-7101	Qualtrics Platform Survey

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: ECA estimates that the Department will, on average, provide awards to approximately 100 grantees per year in the future, in which all will be requested to use Qualtrics for survey creation and distribution.

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Annual Cost to Federal Government: $663,420

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/31/2024

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