OMB No. 0917-0036, Mini-Supporting Statement for Portland Area Division of Environment Health Services: Customer Service Assessm

Request for Approval under the “Generic Clearance for the Collection of
Qualitative Feedback on Agency Service Delivery”
(OMB Control Number: 0917-0036-21)
TITLE OF INFORMATION COLLECTION:
PORTLAND AREA DIVISION OF ENVIRONMENTAL HEALTH SERVICES: CUSTOMER
SERVICE ASSESSMENT

PURPOSE:
The collection of information via a service is necessary to enable IHS to garner customer and
stakeholder feedback in an efficient, timely manner, in accordance with our commitment to
improve service. The information collected from participants is voluntary and will help ensure
that we provide effective, efficient and desired services but IHS will use their responses to
improve services. Personally identifiable information (PII) is provided voluntarily by individuals
who want to have follow-up contact with IHS. IHS will comply with applicable requirements,
restrictions and prohibitions of the Privacy Act and other privacy and confidentiality laws that
govern the agency’s collection, retention, use and/or disclosure of such PII.

DESCRIPTION OF RESPONDENTS:
1. Individuals who receive IHS-DEHS Services.
2. State, local & tribal governments who (a) receive IHS-DEHS services or (b) partner with
IHS-DEHS to provide services.
3. Other Federal Agencies who partner with a & b.

TYPE OF COLLECTION: (Check one)
[x] Customer Satisfaction Survey
[ ] Small Discussion Group
[ ] Other: ______________________

[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group
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.

Celeste L. Davis

Digitally signed by Celeste L. Davis

DN: cn=Celeste L. Davis, o=IHS, ou=DEHS,
Name:________________________________________________
email=celeste.davis@ihs.gov, c=US
Date: 2013.05.02 14:06:31 -07'00'

To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [x] No
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(Voluntarily provides contact
info for a response from IHS)

2. If Yes, will any information that is collected be included in records that are subject to the
Privacy Act of 1974? [ ] Yes [x] No
3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No
Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to
participants? [ ] Yes [x] No

BURDEN HOURS
Category of Respondent

No. of
Participation
Respondents Time

Burden

Individuals who receive IHS-DEHS Services
State, local, tribal governments who receive IHSDEHS Service

50
10

15 minutes
10
15 minutes

12.5
2.5

Totals

60

25
30 minutes

15

FEDERAL COST: The estimated annual cost to the Federal government is ____________
$150.60
An employee spends 2.5 hours at $60.24 per hour to analyze responses, at a GS 14, step
In employee spends 2.5 hours x 70$ hours to analyze responses.
8 wage scale.

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
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 [x] 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?
Response is voluntary for any and all individuals who receive services or assistance from the
program. The group potential is limitless.

Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[X] Web-based or other forms of Social Media
[ ] Telephone
[X] In-person
[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ ] Yes [X] No
Please make sure that all instruments, instructions, and scripts are submitted with the
request.
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Instructions for completing Request for Approval under the “Generic
Clearance for the Collection of Qualitative Feedback on Agency Service
Delivery”
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. Note: 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.
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 per row.
No. 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 and the
participation time and 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.
Submit all instruments, instructions, and scripts are submitted with the request.

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