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### Request for Approval under the **“Generic Clearance for the Collection of Routine Customer Feedback”**  **(OMB Control Number: XXXX -**  **YYYY) TITLE OF INFORMATION COLLECTION:**  **PURPOSE :** 

**DESCRIPTION OF RESPONDENTS** :

**TYPE OF COLLECTION:** (Check one) [ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey [ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group [] Focus Group [ ] Other:

______________________ **C ERTIFICATION:**  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 do es not rais e issues of concern to other federal agencies
. 4. The results are not intended to be disseminated to the p ublic
. 5. In formation 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 review, please provide answers to the fo llowing question: **Personally Identifiable Information:** 1. Is personall y 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 [ ] No2

3. If Applicable, has a S ys tem or Records Notice been published? [ ] Yes [ ] No **Gifts or Payments :**  Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [ ] No

**BURDEN HO UR**  **S Category of Respondent**  **N o.**  **of Respondents**  **Participation**

**Time Burden** 

**Totals**
**FEDERAL COST**  **:** The estimated annual cost to the Federal government is ____________ **If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:**  **The select**  **ion of your targeted respondents** 1. Do y ou have a customer list or something similar that defines the universe o f potential respondents and do you have a sampling plan for selecting from this universe ? [ ] 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 desc ription of how y ou plan to identify y our potential group of respondents and how you will select them ?

**Administration of the Instrument** 1. H ow 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.** 3



### 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 xxxx) **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 collection of information. These groups must have experience with the program. **TYPE OF COLLECTION:** Check one box. If y ou are requesting approval of other instruments under the generic , you must complete a form for each instrument. **CERTIFICATION:** Please read the certification carefully . If y ou incorrectly certify , the collection will be returned as improperl y submitted or it will be disapproved. **Personally Identifiable Information:** Provide answers to the questions. **Gifts or Payments :**  If you answer ye s to the question, please describe the incentive and provide a justification for the amount. **BURDEN HOURS :**  **Category 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 ty pe of respondent can be selected. **No .**  **of Respondents:**  Provide an estimate of the Number of respondents. **Participation Time:** 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) **Burden:** Provide the Annual bur den hours: Multiply the Number of responses and the participation time and divide by 60. **FEDERAL COST:** Provide an estimate of the annual cost to the Federal government
. **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**  **.** P lease provide a description of how you plan to identify your potential group of respondents and how y ou will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment. **Administration of the Instrument :**  Identify how the information will be collected. More than one box may

be checked. Indicate whether there will be interviewers (e.g. for survey s) or facilit ators (e.g., for focus groups) used.4

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