DOCUMENTATION FOR THE GENERIC CLEARANCE

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Request for Approval under the “Generic Clearance for Improving Customer Experience: OMB Circular A-11, Section 280 Implementation” 
(OMB Control Number:     )

TITLE OF INFORMATION COLLECTION:     


TYPE OF ACTIVITY

Select all that apply. 

☐Screener (for example, distributed before or during a usability testing session or other kind of session) 
☐Question script for interview, focus group, discussion group, etc. Scripts for usability testing sessions are, in general, exempt from PRA review subject to the caveats on page 3 of this OMB Memorandum.  
☐Survey to obtain feedback immediately following a transaction -  limited to 15 questions and 5-minutes of burden maximum. 
☐Other survey 

TYPE OF SUBMISSION

☐New collection: Select this if you do not already have an approved collection. 
☐Change to an already approved collection: Select this if you have an already approved collection but are making changes to the questions, the number of respondents, etc.  

Please attach your instrument as a separate document using the Word template that pertains to your particular engagement, i.e., either a survey/screener or script. OMB has prepared special templates that must be used for submitting your instrument. Please ask your agency’s PRA officer for these templates. Do not paste the question list within this document. As a reminder, usability testing session scripts are, in general, exempt from PRA review subject to the caveats on p.3 here, but screeners for those sessions must be submitted for PRA review.  

PURPOSE OF COLLECTION:  
What are you hoping to learn / improve? How do you plan to use what you learn to support service delivery improvement activities? Are there artifacts (user personas, journey maps, digital roadmaps, summary of customer insights to inform service improvements, performance dashboards) the data from this collection will inform?
     

ACTIVITY DETAILS
    1. If this is a survey for a High Impact Service Provider, will the results of this survey be reported to OMB as part of quarterly reporting obligations?  
☐Yes
☐No
☐Not applicable 

    2. How will you collect the information? (Check all that apply)
☐Social Media 
☐Website 
☐Telephone	
☐In-person 
☐Video conference (e.g., Zoom, WebEx, Teams, etc.)
☐Mail 
☐Other, Explain       	

    3. If this is a survey OR a screener, what platform will be used (e.g., Medallia, Microsoft Forms, Qualtrics, SurveyMonkey, Touchpoints, etc.)      

    4. Who will you collect the information from?

Please describe exactly how you will select the people who you will invite to take the screener or survey, or to participate in the session. Some examples:

    • If you are requesting approval for a survey that will appear as a “feedback button” on a website, you can write: “100% of people who visit the website will have the opportunity to take the survey, since the invitation appears on each page of the website.”
    • If you are requesting approval for a focus group to conduct discovery phase research, you can write: “of the people who provided their email address to the call center rep, 15% of them will be selected at random to be invited to take part in the focus group.” 

These are just examples. The key is you must describe the exact methodology you used to determine who gets the invitation to take part in the screener/survey/session. 

     	

    5. Please describe the activity or methodology 
Describe the information collection activity – e.g., what happens when a person agrees to participate? Will facilitators or interviewers be used? What’s the format of the interview/focus group? 
     

    • How will you ask a respondent to provide information? 
(e.g., after an application is submitted online, the final screen will present the opportunity to provide feedback by presenting a link to a feedback form / an actual feedback form)
     

    • When will the activity happen?
Describe the time frame or number of events that will occur (e.g., “We will conduct focus groups on May 13, 14, 15 of XXXX (year)”; “We plan to conduct customer intercept interviews over the course of the summer of XXXX (year) at the field offices identified in response to #2 based on scheduling logistics concluding by Sept. 10th”, or “This survey will remain on our website in alignment with the timing of the overall clearance.” If you are uncertain as to how long it will take to complete your research, you can write: “Until all participants complete/are interviewed.”)
     

    6. Will you be compensating participants? 
It may be appropriate to compensate participants for reasonable out-of-pocket costs and to recruit those who are hard to reach, such as those with multiple jobs or are caretakers. It is not appropriate to compensate those participating in their work capacity and those who are vulnerable to coercion or undue influence such as children and people with certain mental disabilities. 
☐Yes 
☐No  

If yes, please describe: (1) the dollar amount and the type of compensation (e.g., gift card) per participant; (2) the reason you are compensating; and (3) why you believe no one in your sample is vulnerable to coercion or undue influence.  
     

Personally Identifiable Information

Please complete the following questions in coordination with your agency’s privacy office to ensure that the information collection complies with any applicable requirements under the Privacy Act of 1974 (5 U.S.C. § 552a) and other laws and policies:

1. Could any of the questions offer the opportunity for respondents to provide personally identifiable information (PII)?1
☐Yes 
☐No 

2. If the answer to Question 1 is “Yes,” will the information collected be covered by the Privacy Act of 1974? 
☐Yes 
☐No 

3. If the answer to Question 2 is “Yes,” what is the status of the applicable system of records notice(s) (SORNs)?
☐ Published (include citation here) and no modification needed. Include citation:      
☐ Published (include citation here), but modification needed. Include citation:      
☐ No SORN exists; need to publish new SORN(s)

4. If a privacy impact assessment (PIA) is required, please provide a link to where the PIA is published on the agency’s website:      

BURDEN HOURS 

IF YOU SELECTED “NEW COLLECTION” IN RESPONSE TO “TYPE OF SUBMISSION” ON PAGE 1:

Please fill in each applicable cell in the table below. 

IF YOU SELECTED “CHANGE TO AN ALREADY APPROVED COLLECTION” IN RESPONSE TO “TYPE OF SUBMISSION” ON PAGE 1:

First, you must figure out whether your change will affect the number of respondents per year or the participation time for the instrument.

    • If the number of respondents and the participation time are both staying the same: input “1” for “No. of Respondents per year,” input 60 for “Participation Time in minutes,” and input “1” for “Total Burden per year in hrs.” This is because “1 hour” is the minimum that can be inputted into ROCIS for total burden hours. 
    • If the number of respondents or the participation time is changing: Contact the CX Desk Officer before completing this table. 

Type of Instrument 
No. of Respondents per year
Participation Time in minutes 
Total Burden per year in hrs 
Screener (e.g., distributed before or during a usability testing session or other kind of session)
     
     
     
Question script for focus group, interview group, etc. See discussion of usability testing on page 1. 
     
     
     
Survey to obtain feedback immediately following a transaction
     
Insert value less than or equal to 5
     
Other survey
     

     
Totals
     
     
     

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

I certify the following to be true: 
    1. The collections are voluntary;
    2. The collections are low-burden for respondents (based on considerations of total burden hours or burden-hours per respondent) and are low-cost for both the respondents and the Federal Government;
    3. The collections are non-controversial, meaning they do not raise issues that warrant public comment;
    4. Any 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 near future;
    5. Personally identifiable information (PII) is collected only to the extent necessary and the agency will comply with applicable legal and policy requirements to ensure its protection;
    6. Information gathered is intended to be used for general service improvement and program management purposes;
    7. The agency will follow the procedures specified in any relevant OMB guidance for the required reporting to OMB of data from surveys; 
    8. Outside of the reporting mentioned in the bullet immediately above, if the agency intends to release journey maps, user personas, reports, or other data-related summaries stemming from this collection, the agency must include appropriate caveats around those summaries, noting that conclusions should not be generalized beyond the sample, considering the sample size and response rates. The agency must submit the data summary itself (e.g., the report) and the caveat language mentioned above to OMB before it releases them outside the agency. OMB will engage in a passback process with the agency.  

Name of Person(s) who developed the screener/question script/survey:      
Email address of the above person(s):