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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

T ITLE OF INFORMATION COLLECTION: Summit Evaluation

PURPOSE:

This survey will be utilized as a voluntary measure of agency government employees, military members, and civilians experience of the Regional Discussion on Sexual Assault and Sexual Harassment Achieving Cultural Change Through Data and an Evaluation Mindset.

The information will be assembled and provided to the discussion’s senior leadership for information/action.

The information is aimed at determining whether the discussion met the goals set forth by the discussion organizers and any improvements that could be made to future discussions.

DESCRIPTION OF RESPONDENTS:

Agency government employees, military members, and civilians who attend the discussion.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [X] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software) [ ] Small Discussion Group

[ ] Focus Group [X] Other: Discussion Evaluation

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.

Name: CDR Leedjia Svec

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [ X] No

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 NA

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 Respondents	Participation Time	Burden
Agency Government Contractor Employees	150	5	12.5 hours
Totals	150	5 minutes	12.5 hours

FEDERAL COST: The estimated annual cost to the Federal government is $90.62

Cost estimate reached from multiplying 7.25 (federal minimum wage) with 6.25 (total burden hours).

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? [X] Yes [] No

We will have the summit attendee e-mails from their registration to attend the summit.

We will e-mail the summit attendees with a link to take the survey voluntarily.

We will use the verint software system which enables this to be done securely.

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

[ ] In-person

[ ] Mail

[ ] Other, Explain:

2. Will interviewers or facilitators be used? [ ] Yes [ X ] No

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