Draft Generic Appliation Template

Request for Approval under the

“Generic Clearance for FEMA’s Collection of Qualitative Feedback on Agency Service Delivery”
(OMB Control Number: 1660-0130)

(Please refer to the instructions starting on page 4.)

TITLE OF SUB-COLLECTION:
FEMA Form FF-xxx-FY-xx-xxx (formerly xxx-x-xx), Name of Instrument(s)

PURPOSE:

LEGISLATIVE AUTHORITIES (if applicable):

TYPE OF RESPONDENTS: (Check one)

[ ] Individuals and Households [ ] Private Sector

[ ] State, Local, or Tribal Governments [ ] Federal Government

TYPE OF COLLECTION INSTRUMENT: (Check one)

[ ] Customer Satisfaction Surveys [ ] Focus Groups

[ ] Other Course Evaluation [ ] Customer Comment Card

[ ] Other:

PRIVACY INFORMATION:

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

2. Is there a Privacy Threshold Analysis (PTA) approved by DHS? [ ] Yes [ ] No

   1. Date of Approval:

3. Is Privacy Impact Assessment (PIA) coverage required? [ ] Yes [ ] No

   1. Applicable PIA(s):

4. Is System of Records Notice (SORN) coverage required? [ ] Yes [ ] No

   1. Applicable SORN(s):

ELECTRONIC COLLECTION

1. What percentage of responses are collected by electronic means?

2. What is the website URL or email address that collects the responses?

GIFTS OR PAYMENTS:

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

USABILITY TESTING:

1. Has useability testing been conducted on this instrument? [ ] Yes [ ] No

2. Please provide a short narrative answering the following questions about your usability testing.

• What was the purpose of the usability testing?

• How was the useability testing conducted?

• How many participants and what was their familiarity with the collection?

• What were the results of the useability testing?

• What did you find (burden, ease of use, etc.)?

• What did the participants recommend?

• What changes, if any, will be made to the collection?

BURDEN:

Estimated Annualized Burden Hours and Costs
Type of Respondent	Form Name / Form No.	No. of Respondents	No. of Responses per Respondent	Total No. of Responses	Avg. Burden per Response (in hours)	Total Annual Burden (in Hours)	Avg. Hourly Wage Rate	Total Annual Respondent Cost
Totals

FEDERAL COST: The estimated annual cost to the Federal Government is $____________.

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection information is low-burden for respondents and are low-cost for both the respondents and the Federal Government.

3. The collection of information 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.

7. All instruments have undergone usability testing to improve the customer experience for respondents.

Digital Signature:

Please make sure that all instruments, privacy documents (PTA, PIA, and/or SORN), instructions, and scripts are submitted with the request.

Instructions for Completing Request for Approval under the “Generic Clearance for FEMA’s Collection of Qualitative Feedback on Agency Service Delivery”
(OMB Control Number: 1660-0130)

TITLE OF INFORMATION COLLECTION: Provide the name of the instrument being submitted as a sub-collection and the FEMA Form Number.
(Format: “FEMA Form FF-xxx-FY-xx-xxx (formerly xxx-x-xx), Name of Instrument”)

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.

LEGISLATIVE AUTHORITY: Please list any Public Laws, statutes, Executive Orders, regulations, Department policies, and/or Agency policies that authorize FEMA to collect and use this information. Please use correct legal citation in a simple list.

TYPE 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.

TYPE OF COLLECTION INSTRUMENT: Select one of the provided options. If you are requesting approval of other instruments under the generic, you must complete an application for each instrument.

PRIVACY INFORMATION: Please select a provided option for each of the numbered questions. For any questions that you select “Yes”, please provide the requested information in the second line. Please contact FEMA’s Privacy Division at FEMA-Privacy@fema.dhs.gov for any questions regarding your PTA, PIA, SORN or other privacy documents.

ELECTRONIC COLLECTION: Please provide answers to the questions.

GIFTS OR PAYMENTS: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

USABILITY TESTING: Please provide answers to the questions. Testing should be completed prior to submitting this application to FEMA’s PRA Office.

BURDEN HOURS: If you have questions about how to calculate these numbers, please reach out to the economists in the Office of Chief Counsel's Regulatory Affairs Division (Point of Contact: Michael Conforti, Jr at michael.confortijr@fema.dhs.gov).

Type of Respondent: 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.

Form Name / Form No.: Provide the name of the instrument and the FEMA Form Number.

No. of Respondents: Provide an estimate of the number of Respondents.

No. of Responses per Respondent: Provide an estimate of how many times a year that each Respondent is expected to provide a response.

Total No. of Responses: Multiply the number of Respondents from the third column and the number of responses per Respondent in the fourth column to determine the total number of responses.

Avg. Burden per Response (in hours): Provide an estimate of the amount of time required for a respondent to complete the instrument in hours (See DHS’s Burden Conversion Table for conversion of minutes to decimal units of an hour).

Total Annual Burden (in hours): Multiply the total number of responses in the fifth column and the average burden per response from the sixth column to determine the total annual burden for the instrument.

Avg. Hourly Wage Rate: Enter the fully-loaded wage rate in this column. Determine the fully-loaded wage rate by multiplying the non-loaded “Avg. Hourly Wage Rate” from the Bureau of Labor Statistics (BLS) Employer Costs for Employee Compensation, Table 1 by either a wage rate multiplier of 1.61 for State, Local, or Tribal Government or a wage rate multiplier of 1.45 for Federal Government.

Total Annual Respondent Cost: Multiply the total annual burden (in hours) in the seventh column and the average hourly wage rate from the eighth column to determine the total annual respondent cost for the instrument.

Totals: Add up the totals for number of Respondents for all instruments in this submission in the third column, the total number of responses for all instruments in this submission in the fifth column, the total annual burden hours in the seventh column, and the total annual respondent cost in the ninth column in the bottom row.

FEDERAL COST: Provide an estimate of the annual cost to the Federal Government. This is the total amount of contract costs, staff salaries, special facilities, computer equipment and other associated costs that you would list in Question 14 of the Supporting Statement A. We just need the total.

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

DIGITAL SIGNATURE: Apply the digital signature of the appropriate official within the Program Office; Branch Chief or higher.

Please make sure that all instruments, privacy documents (PTA, PIA, and/or SORN), instructions, and scripts are submitted with the request.

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