Form 001-xx (TBD) 001-xx (TBD) Fast Track Clerance Submission

Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery” (OMB Control Number: 2105-0573)

TITLE OF INFORMATION COLLECTION: Feedback survey for National Roadway Safety Strategy (NRSS) Allies in Action stakeholders on the National Roadway Safety Strategy (NRSS) Call to Action initiated by the U.S. Department of Transportation (DOT) in February 2023

PURPOSE: The data collection described in this document will support the DOT in receiving feedback from its NRSS Allies in Action stakeholders on the NRSS Call to Action initiated by DOT in February 2023. A brief e-survey will be provided to Allies in Action stakeholders who have formally made a commitment to support the NRSS Call to Action to measure their level of progress and impacts of NRSS Call to Action commitments and to identify additional ways that the DOT can support their continued engagement in the NRSS Call to Action. (Expected burden per response < 15 minutes)

DESCRIPTION OF RESPONDENTS: Allies in Action stakeholders include Federal, state, local, territorial and tribal transportation agencies, planning organizations (metropolitan planning organizations, councils of governments, regional councils, etc.), trade associations, private sector organizations (e.g., engineering firms, consulting companies, technology companies, equipment vendors, etc.), non-profit organizations, colleges and universities and others. At this time, the DOT has approximately 125 Allies in Action stakeholders who have made a commitment to support the NRSS Call to Action.

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 [ ] Other: ______________________

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: Amie Kalsbeek, U.S. DOT, Office of the Secretary, Office of Policy Coordination and Development (OST-P) .

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 [ ] 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 Respondents	Participation Time	Burden1
State, county, local, territorial and tribal government agencies	20	15 minutes	5 hours
Industry associations or non-profits	20	15 minutes	5 hours
Private sector (consultants, engineers, technology vendors)	50	15 minutes	12 hours and 30 minutes
Individuals (students, academics, other)	50	15 minutes	1 hour and 15 minutes
Totals	140	15 minutes	35 hours

TOTAL BURDEN HOURS:

FEDERAL COST: The estimated annual cost to the Federal government is __$1,081.80___

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

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?

A brief e-survey will be provided to Allies in Action stakeholders who have formally made a commitment to support the NRSS Call to Action – found here.

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

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

ATTACHMENT A

OMB CONTROL NUMBER: 2105-0573
EXPIRATION DATE: mm/dd/yyyy

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2105-0573. Public reporting for this collection of information is estimated to be approximately 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information.

All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Amie Kalsbeek, amie.kalsbeek@dot.gov and NRSS@dot.gov, 202-557-0402, U.S. Department of Transportation, 1200 New Jersey Ave, SE, Washington, D.C. 20590.

Survey Questions

Thank you for your continued partnership in the U.S. Department of Transportation National Roadway Safety Strategy Call to Action. Please answer the questions below to help the U.S. Department of Transportation gain perspective on your experience as an Ally in Action and identify opportunities for the U.S. Department of Transportation.

1. For each of the statements below, indicate your level of agreement or disagreement. Please select one response in each row. Enter response below.

Call to Action Objectives Feedback	Agree strongly	Agree somewhat	Neither agree nor disagree	Disagree somewhat	Disagree strongly
Overall, do you feel that the Call to Action has brought value to your organization and its efforts to take steps to actively reduce the # of deaths and serious injuries on America’s roads and streets?
Overall, do you feel that the Call to Action has brought value to your organization and its efforts to expand adoption of a Safe System Approach and a Zero Fatalities vision?
Overall, do you feel that the Call to Action has brought value to your organization and its efforts to transform how we as a nation think about road safety?

2. Have you made progress on your commitment made as an Ally in Action? If so, how? Enter response below.

3. Are there any already available metrics that you can share related to any commitment progress you have made? Enter response below.

4. Have you shared your Call-to-Action progress publicly? Did you receive any feedback from sharing? Enter response below.

5. Please share any links to public-facing updates on your commitment to the Call to Action. Enter response below.

6. What can USDOT do to better support your organization’s involvement as an Ally in Action? (For example, calling attention to allies, providing information on additional resources, more frequent updates or opportunities to collaborate, etc.) Enter response below.

7. Do you have any other feedback related to DOT’s NRSS Call to Action? Enter response below.

1 Totals may not add due to rounding.

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