FDG Screener Survey

PAPERWORK REDUCTION ACT NOTICE
The information collected will be used for the U.S. Government to help improve the
customer experience on the fiscaldata.treasury.gov website. The estimated burden
associated with this collection of information is 5 minutes per response. Comments
concerning the accuracy of this burden estimate and suggestions for reducing this
burden should be directed to the Department of Treasury, Bureau of the Fiscal Service,
Forms Management Officer, Parkersburg, WV 26106-1328 or email us
at GraphicsandPrinting@fiscal.treasury.gov. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a
valid control number assigned by OMB. The OMB number for this study is 1530-0023.

FDG Screener Survey
Updated April 13, 2023

Title

Research Participation Interest Form

Description

We're grateful for your interest in helping the Bureau of Fiscal Service to learn more about the
needs of the people we serve!
Please fill out the form below and we will reach out about any future research opportunities
that you qualify for.
[Data Usage]
The information collected in this survey will only be used to ensure that we seek feedback about
our services from a diverse group of individuals. This data will never be shared outside of our
team or used for other purposes.
To learn more about how we protect your personal information, please visit
https://www.fiscal.treasury.gov/privacy.html
[Data Removal]

3

If you later decide you no longer want to be contacted about research opportunities, please
reach out to [_____] about removing your data from our database.

Fields

•
•
•
•

First Name – Text Input
Last Name – Text Input
Email — Email Input
Age Range – Single Select o 18 or younger o 18 – 25 o 26 – 35 o 36 – 45 o 46 – 60 o 60
– 75 o 76 or older

•

Race or Ethnicity – Multiselect o Native American or Alaskan Native o Black or African
American o Asian or Pacific Island o Hispanic or Latino o White or Caucasian o Other or
Not Listed

•

Job Title – Text Input

Post-Submission Message

Thank you for your time and enthusiasm to help improve government services!

4