# Instructions for Completing Supporting Statement for DOI Generic Clearance Submission, OMB Approval Number 1040-0001  {#instructions-for-completing-supporting-statement-for-doi-generic-clearance-submission-omb-approval-number-1040-0001 .unnumbered}

1.  **Survey Title/Date Submitted to the Office of Planning and
    Performance Management (PPP)**: Insert title for the proposed
    survey. Insert date that the expedited approval package will be
    submitted to PPP. Reminder: Please submit the package through your
    bureau/office Information Collection Officer.

2.  **Bureau/Office:** Insert the name of the bureau/office conducting
    the survey.

3.  **Abstract:** Summarize the proposed study with an abstract not to
    exceed 150 words.

4.  **Bureau/Office Point of Contact Information:** Complete the
    bureau/office contact information. PPP will communicate with the
    point of contact listed here throughout the entire approval process.

5.  **Principal Investigator (PI) Conducting the Survey:** Complete
    information about the PI who will be conducting the survey, if
    different than Point of Contact listed in #4. Otherwise note: Same
    as #4.

6.  **Name of Program Office Conducting Survey:** Provide the name of
    the bureau program, office, or organizational unit conducting the
    survey.

7.  **Description of Customers/Services Provided:** Provide a brief
    description of the customers who will be surveyed, the services
    provided by the program conducting the survey, and how these
    services are provided to customers.

8.  **Survey Dates:** List the time period in which the survey will be
    conducted, including specific starting and ending dates. The
    starting date should be at least ***45*** days after the submission
    date. The request for expedited approval, and submission of a
    complete and accurate approval package, must be made at least
    ***45*** calendar days prior to the first day the PI wishes to
    administer the survey instrument to the public.

9.  **Type of Information Collection Instrument:** Check the type(s) of
    information collection instrument(s) that will be used. If other,
    please explain.

10. **Survey Development:** Explain how the survey was developed. With
    whom did you consult during the development of the survey on
    content? On statistics? Did you pretest the survey? What actions did
    you take to improve the survey? What suggestions did you receive for
    improving the survey? (Note: A description of any pre-testing and
    peer review of the methods and/or instrument is highly recommended.)

11. **Survey Methodology:** Explain how the survey will be conducted.
    Provide a description of the survey methodology including: (a) How
    will the customers be sampled? (if fewer than all customers will be
    surveyed); (b) What percentage of customers asked to take the survey
    will respond, and (c) What actions are planned to increase the
    response rate? If statistics are generated, this description must be
    specific and include each of the following:

-   The respondent universe,

-   The sampling plan and all sampling procedures, including how
    individual respondents will be selected;

-   How the instrument will be administered;

-   Expected response rate and confidence levels (note: OMB encourages
    agencies to target a minimum response rate of 70%); and

-   Strategies for dealing with potential non-response bias.

Note: Web-based surveys are not an acceptable method of sampling a broad
population. Web-based surveys must be limited to services provided by
the web.

12. **Total Number of Initial Contacts/Expected Number of Respondents:**
    Provide an estimated total number of initial contacts and the total
    number of expected respondents.

13. **Estimated Time to Complete Initial Contact/Instrument:** Estimate
    the time to complete the initial contact and the survey instrument
    (in minutes).

14. **Total Burden Hours:** Provide the total number of burden hours.
    The total burden hours should account for the amount of time
    required to instruct the respondents in completing the survey, and
    the amount of time required for the respondent to complete the
    survey.

15. **Reporting Plan:** Provide a brief description of the reporting
    plan for the data being collected. A copy of all survey reports must
    be archived with the PPP. Please note this in the reporting plan.

16. **Justification, Purpose and Use:** Provide a brief justification
    for the survey, its purpose, goals, and utility to managers.
    Specifically, describe how data will be tabulated and what
    statistical techniques will be used to generalize the results to the
    entire customer population. Describe how data from the survey will
    be used. Describe how you will acknowledge any limitations related
    to the data, particularly in cases where we obtain a lower than
    anticipated response rate. Note whether or not the survey is
    intended to measure a Government Performance and Results Act (GPRA)
    performance measure.

**Approval Form for DOI Programmatic Clearance for Customer Satisfaction
Surveys (OMB Control Number 1040-0001, Expiration Date: March 31,
2006)**

+-----------------------------------+-----------------------------------+
| **U.S. Department of the          | **PPP Tracking Number: *(for PPP  |
| Interior**                        | use only)***                      |
|                                   |                                   |
| Office of Planning and            |                                   |
| Performance Management (PPP)      |                                   |
+-----------------------------------+-----------------------------------+

  ----- ------------- ------------------------------ ------------------------
  1\.   **Survey                                     Date Submitted to PPP:
        Title:**                                     

  2\.   **Bureau:**                                  
  ----- ------------- ------------------------------ ------------------------

  ----- --------------- ------------------------------------------------------
  3\.   **Abstract:**   

                        (not to exceed 150 words)
  ----- --------------- ------------------------------------------------------

  ----- -------------------- --------------- ------------ --------- -- -- -- ---------- ---- -- -- ------ -- -----------
  4\.   **Bureau/Office                                                                                      
        Point of Contact                                                                                     
        Information**                                                                                        

        **First Name:**                                   **Last                                             
                                                          Name:**                                            

                                                                                                             

        **Title:**                                                                                           

                                                                                                             

        **Bureau/Office:**                                                                                   

                                                                                                             

        **Street Address:**                                                                                  

                                                                                                             

        **City:**                            **State:**                      **Zip                           
                                                                             code:**                         

                                                                                                             

        **Phone:**                           **Fax:**                                                        

                                                                                                             

        **Email:**                                                                                           

  5\.   **Principal                                                                                          
        Investigator (PI)                                                                                    
        Information**                                                                                        

        **First Name:**                                   **Last                                             
                                                          Name:**                                            

                                                                                                             

        **Title:**                                                                                           

                                                                                                             

        **Bureau/Office:**                                                                                   

                                                                                                             

        **Address:**                                                                                         

                                                                                                             

                                                                                                             

                                                                                                             

        **City:**                            **State:**                      **Zip:**                        

                                                                                                             

        **Phone:**                           **Fax:**                                                        

                                                                                                             

        **Email:**                                                                                           
  ----- -------------------- --------------- ------------ --------- -- -- -- ---------- ---- -- -- ------ -- -----------

+---+------------+-----------+----+----+----+-------+----+---------+
|   |            |           |    |    |    |       |    |         |
+---+------------+-----------+----+----+----+-------+----+---------+
| 6 | **Name of  |           |    |    |    |       |    |         |
| \ | Program or |           |    |    |    |       |    |         |
| . | Office     |           |    |    |    |       |    |         |
|   | Conducting |           |    |    |    |       |    |         |
|   | Survey:**  |           |    |    |    |       |    |         |
+---+------------+-----------+----+----+----+-------+----+---------+
| 7 | **D        |           |    |    |    |       |    |         |
| \ | escription |           |    |    |    |       |    |         |
| . | of         |           |    |    |    |       |    |         |
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|   | stomers/** |           |    |    |    |       |    |         |
|   |            |           |    |    |    |       |    |         |
|   | **Services |           |    |    |    |       |    |         |
|   | P          |           |    |    |    |       |    |         |
|   | rovided:** |           |    |    |    |       |    |         |
+---+------------+-----------+----+----+----+-------+----+---------+
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+---+------------+-----------+----+----+----+-------+----+---------+
|   |            |           |    |    |    |       |    |         |
+---+------------+-----------+----+----+----+-------+----+---------+
| 9 | **Type of  |           |    |    |    |       |    |         |
| \ | I          |           |    |    |    |       |    |         |
| . | nformation |           |    |    |    |       |    |         |
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|   | (Check ALL |           |    |    |    |       |    |         |
|   | that       |           |    |    |    |       |    |         |
|   | Apply)**   |           |    |    |    |       |    |         |
+---+------------+-----------+----+----+----+-------+----+---------+
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+---+------------+-----------+----+----+----+-------+----+---------+
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| 0 | Deve       |           |    |    |    |       |    |         |
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|   | Was the    |           |    |    |    |       |    |         |
|   | survey     |           |    |    |    |       |    |         |
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|   | How were   |           |    |    |    |       |    |         |
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+---+------------+-----------+----+----+----+-------+----+---------+
|   |            |           |    |    |    |       |    |         |
+---+------------+-----------+----+----+----+-------+----+---------+

<table style="width:100%;">
<colgroup>
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 11%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 9%" />
<col style="width: 5%" />
<col style="width: 17%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 9%" />
<col style="width: 5%" />
<col style="width: 6%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="13"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">11.</td>
<td colspan="2"><p><strong>Survey Methodology:</strong> (Use as much
space as needed; if necessary include additional explanation on</p>
<p>separate page.)</p></td>
<td colspan="10"><ol type="a">
<li><p>Respondent universe:</p></li>
<li><p>Sampling plan/procedures:</p></li>
<li><p>Instrument administration:</p></li>
<li><p>Expected response rate/confidence levels:</p></li>
<li><p>Strategies for dealing with potential non-response bias:</p></li>
<li><p>Description of any pre-testing and peer review of the methods
and/or instrument (recommended):</p></li>
</ol></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="2">12.</td>
<td colspan="3">Total Number of Initial Contacts/ Expected Number of
Respondents:</td>
<td colspan="2"></td>
<td></td>
<td>13.</td>
<td>Estimated Time to Complete Initial Contact | Instrument
(mins.):</td>
<td></td>
<td></td>
<td>14.</td>
<td>Total Burden Hours:</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">15.</td>
<td colspan="2"><strong>Reporting Plan:</strong></td>
<td colspan="10"></td>
</tr>
</tbody>
</table>

> **16. Justification, Purpose, and Use:**
>
> Survey Justification and Purpose:
>
> Survey Goals:

Utility to Managers:

How will the results of the survey be analyzed and used?

> How will the data be tabulated? What Statistical Techniques will be
> used to generalize the results to the entire customer population? How
> will limitations on use of data be handled?
>
> If the survey results in a lower than anticipated response rate, how
> will you address this
>
> when reporting the results?
>
> Is this survey intended to measure a Government Performance and
> Results Act (GPRA) performance measure? If so, please include an
> excerpt from the appropriate document.

# Checklist for Submitting a Request to Use DOI Programmatic Clearance for Customer Satisfaction Surveys

-   ***All*** questions in the survey instrument are within the scope of
    one of the DOI Programmatic Clearance for Customer Satisfaction
    Surveys topic areas.

-   The approval package is being submitted to the Office of Planning
    and Performance Management at least ***45*** days prior to the first
    day the PI wishes to administer the survey to the public.

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-   A qualified statistician has reviewed and approved your request.

-   Your bureau/office Information Collection Officer has reviewed and
    approved the approval package.

The approval package includes:

-   a completed Information Form

-   a signed Certification Form

a copy of the survey instrument

other supporting materials, such as

cover letters to accompany mail-back questionnaires

introductory scripts for initial contact of respondents

necessary Paperwork Reduction Act compliance language

follow-up letters/reminders sent to respondents

The survey methodology presented on the Information Form includes a
specific description of:

\(a\) the respondent universe

\(b\) the sampling plan and all sampling procedures, including how
respondents will be selected

\(c\) how the instrument will be administered

\(d\) expected response rate and confidence levels

\(e\) strategies for dealing with potential non-response bias

\(f\) a description of any pre-testing and peer review of the methods
and/or the instrument is highly recommended.

-   The burden hours reported on the Information Form include the number
    of burden hours associated with the initial contact of all
    individuals in the sample (i.e., including refusals), if applicable,
    and the number of burden hours associated with individuals expected
    to complete the survey instrument.

-   The package is properly formatted (Word) and submitted to the Office
    of Planning and Performance Management electronically.

**Electronic copies of this document, the entire Generic Clearance
package, and required forms and checklists are available on Interior's
Office of Planning and Performance Management website at:**
[www.doi.gov/ppp](http://www.doi.gov/ppp)

# CERTIFICATION FORM FOR PAPERWORK REDUCTION ACT DOI GENERIC CLEARANCE SUBMISSION UNDER OMB APPROVAL NUMBER 1040-0001 {#certification-form-for-paperwork-reduction-act-doi-generic-clearance-submission-under-omb-approval-number-1040-0001 .unnumbered}

# 

This form should only be used if you are submitting a collection of
information for approval under the DOI Programmatic (Generic) Clearance
for Customer Satisfaction Surveys, assigned OMB approval number
1040-0001, valid until March 31, 2006.

If the collection does not satisfy the requirements of the program
clearance, you should follow the regular Paperwork Reduction Act
clearance procedures described in 5 CFR 1320.

Bureau/Office Subgroup or Program:

Title *(Please be specific)*:

Burden Hour Estimates

No. of Respondents: Hours/Min Per Response: Total Burden Hours:

Bureau/Office Contact (person who can best answer questions about the
content of the submission):

Name:

Phone:

Certification: The collection of information requested by this
submission meets the requirements of the OMB approval number 1040-0001.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Bureau/Office Qualified Statistician ­ DATE

Bureau/Office Information Collection Officer DATE

Office of Planning and Performance Management DATE

OMB, Office of Information and Regulatory Affairs (OIRA) DATE