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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0648 Exp., date: 06/2024)

TITLE OF INFORMATION COLLECTION:

PURPOSE:

DESCRIPTION OF RESPONDENTS:

TYPE OF COLLECTION: (Check one)

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

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

[ ] Focus Group [ ] Other: _______________

FREQUENCY OF REPORTING: (Check one)

[ ] Once [ ] Hourly [ ] Daily

[ ] Weekly [ ] Monthly [ ] Quarterly

[ ] Semi-Annually [ ] Annually [ ] On Occasion

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is a low burden for respondents and a 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: ________________________________________________

To assist with the review, please provide answers to the following questions:

Personally Identifiable Information:

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

2. If yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No

4. Privacy Act Systems of Records Title: _______________________ FR Citation ____FR___

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, a token of appreciation) provided to participants? [ ] Yes [ ] No

ESTIMATED BURDEN HOURS and COSTS

Category of Respondent	No. of Respondents	No. of Responses per Respondent	Time per Response (in hours)	Total Burden Hours
Totals

Category of Respondent	Total Burden Hours	Hourly Wage Rate*	Total Burden Cost
Totals

*Cite source per bls.gov, https://www.bls.gov/oes/current/oes_nat.htm#00-0000 if applicable, or other source

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

Staff	Grade/Step	Salary*	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Contractor Cost
Overhead/Supplies
Other Cost
Total

*Cite salary source from current GS Pay Scale or other source.

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 [ ] No

2. If the answer is yes, please provide a description of both below and 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. You will need to include the number of persons in your customer list and indicate what percentage you anticipate will respond, which will equate to your estimated respondents.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

Please make sure that all instruments, instructions, and scripts are submitted with the request.

PLEASE DO NOT SUBMIT INSTRUCTIONS WITH FINAL REQUEST

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

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 xx)

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 information collection. 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.

FREQUENCY OF REPORTING: Check one box. Please ensure the frequency is captured in the Estimated Burden Hours and Costs.

i.e., Monthly surveys would be 12 multiplied by the number of respondents for each month.

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

Personally Identifiable Information: Provide answers to the questions.

Gifts or Payments: If you answer yes to the question, please describe the incentive and justify the amount.

Personally Identifiable Information: How to answer questions number 1-4:

1. If any of the following apply, the answer is “yes”:

   1. Any representation of information that permits the identity of an individual to whom the information applies to be reasonably inferred by either direct or indirect means. Further, PII is defined as information: (i) that directly identifies an individual (e.g., name, address, social security number or other identifying number or code, telephone number, email address, etc.) or (ii) by which an agency intends to identify specific individuals in conjunction with other data elements, i.e., indirect identification. (These data elements may include a combination of gender, race, birth date, geographic indicator, and other descriptors). Additionally, information permitting a specific individual's physical or online contact is the same as personally identifiable information. This information can be maintained on paper, electronic, or other media.

2. Privacy Act System of Records (PA SOR) - Defined as a group of any records under the control of any agency from which information is retrieved by the name of the individual or by some identifying number, symbol, or other identifying particular assigned to the individual 5 U.S.C. 552a(a)(5):

   1. If the system is NOT a PA SOR - Number 2 is “no”, and numbers 3 and 4 would be NA.

   2. If a system is a PA SOR, Number 2 would be “yes”,

3. If numbers 2 and 3 are “yes,” the response here should be “yes,” but confirm with the IC Privacy Coordinator (IC PC) if question 4 is blank.

4. The system owner and IC PC can find this information on the HHS Privacy Act SORN Page and should review the applicable SORN (if number 2 is “yes”) to confirm that the use case matches the SORN.

BURDEN HOURS and COSTS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households; (2) Private Sector (for profit or not-for-profit); (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.

Average Burden per Response: 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). Describe the amount in fractions if the time is less than an hour (e.g., 5 minutes would be 5/60)

Total Burden Hours: Provide the number of burden hours by multiplying the # of responses x the # of responses per respondent x the average burden per response.

Burden Cost: Multiply Total Burden Hours by Wage Rate to get the Total Burden Cost.

FEDERAL COST: Provide an annual cost estimate to the Federal government. Fill out the table to itemize the Federal cost of the collection. There should be a federal cost at a minimum.

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 to the first question is yes, please attach the sampling plan.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether interviewers (e.g., for surveys) or facilitators (e.g., for focus groups) will be used.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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