FSIS 1360-18 (03/12/2024)a Page 1 of 4

U.S. DEPARTMENT OF AGRICULTURE 

FOOD SAFETY AND INSPECTION SERVICE 

Survey Request Form 

Office of Planning, Analysis and Risk Management (OPARM) 

Thank you for contacting the Strategic Planning and Evaluation Branch (SPEB) within OPARM to assist you with your survey or to 

inquire about survey services. 

Please complete this electronic form to help clarify the purpose and scope of your request. All questions with an asterisk (*) are 

required. The information you provide will help us better identify your specific needs, assign appropriate SPEB resources, and quickly 

achieve an agreed upon plan of action. 

Please submit your completed form to OPARMSPEB@usda.gov. For your convenience, selecting the 'Submit Form' button at the 

bottom of page 4 will open a new e-mail with your form attached and addressed appropriately for submission. 

All survey data collected will belong to the sponsoring Program Area. SPEB will remain objective when reviewing data and reporting 

results and will maintain the confidentiality of all data. Data will only be distributed to the sponsoring Program Area unless prior written 

approval is provided with clear parameters for release. 

PROGRAM AREA POINT OF CONTACT 

Enter the sponsoring Program Area's point of contact information below. 

1. Name:* (First, Last) 2. Program Area:*

3. Staff: 4. E-mail:* (Firstname.last@usda.gov) 5. Work Phone:* (1234567890)

6. What is the title of this survey project?*

SURVEY PURPOSE AND DISTRIBUTION 

7. Provide a brief background regarding the intent and purpose of the survey:*

8. How will the sponsoring Program Area use the survey results?*

9. To whom will the sponsoring Program Area distribute the survey results?* (Select all that apply) 

 Within Program Area FSIS Senior Executives External to FSIS Other areas within FSIS USDA

10. Provide a summary of distribution plans below:*
FSIS 1360-18 (03/12/2024)a Page 2 of 4

Survey Request Form 

SURVEY RESPONDENTS

11. In which area(s) are the respondents who will be surveyed?* (Select all that apply) 

 Agency-Wide: (When selecting this option there is not a need to select each Program Area below)

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 Office of the Administrator (OA)

 Office of the Chief Information Officer (OCIO)

 Office of the Chief Financial Officer (OCFO)

 Office of Planning, Analysis and Risk Management (OPARM)

 Office of Field Operations (OFO)

 Office of Investigation, Enforcement and Audit (OIEA)

 Office of Management (OM)

 Office of Employee Experience and Development (OEED)

 Office of Public Affairs and Consumer Education (OPACE)

 Office of Policy and Program Development (OPPD)

 Office of Public Health Science (OPHS)

 Office of International Coordination (OIC)

 Civil Rights Staff (CRS)

 Internal Affairs (IA)

 External to FSIS: Industry Plant Management 

 External to FSIS: Industry Plant Employees 

 External to FSIS: Other Specific Population 

Details of the external to FSIS selection(s):

12. Are there specific positions the survey will be sent to?* (e.g., Field Inspectors, Laboratory Personnel, Supervisors, etc.)

 Yes (Please Specify)

 No

13. Does the survey audience include Bargaining Unit Employees?* 

 Yes

 No

 Possibly/unknown

14. Has concurrence been obtained from the supervisor or Assistant Administrator of the sponsoring Program Area?

 Yes (Specify whom)

 No

15. Has concurrence been obtained from the Assistant Administrator(s) for all potential respondents?* 

 Yes (Specify whom)

 No
FSIS 1360-18 (03/12/2024)a Page 3 of 4

Survey Request Form 

FSIS STRATEGIC GOALS AND OBJECTIVES 

16. Which of the following FSIS Strategic Goals and Objectives align with the survey request?* (Select all that apply)

GOAL 1: Prevent Foodborne Illness and Protect Public Health 

 1.1.1: Strengthen Compliance with Food Safety Statutes and Regulations 

 1.1.2: Achieve Pathogen Reduction 

 1.1.3: Assure Labeling is Truthful and Not Misleading

 1.2.1: Strengthen Food Safety Practices Throughout the Supply Chain 

 1.2.2: Enhance Collaborative Response to Foodborne Illness Outbreaks and Other Public Health Incidents 

 1.2.3: Raise Consumer Awareness of Food Safety

GOAL 2: Transform Inspection Strategies, Policies, and Scientific Approaches to Improve Public Health 

 2.1.1: Advance and Adopt Innovative Regulatory Policies and Inspection Verification Procedures 

 2.1.2: Foster the Adoption of Advanced Scientific Techniques 

 2.2.1: Improve the Integrity, Accessibility, and Utility of Data

 2.2.2: Strengthen Data Analyses and Evaluations

 2.2.3: Optimize the Design of Sampling Programs for Decision Making 

GOAL 3: Achieve Operational Excellence 

 3.1.1: Expand Recruitment and Increase Retention for Mission-Critical Positions

 3.1.2: Enhance Employee Training and Professional Development 

 3.1.3: Ensure Equal Opportunity, Civil Rights, Diversity, Equity, Inclusion, and Accessibility in the Work Environment 

 3.2.1: Enhance Effectiveness and Efficiency of Key Business Processes

 3.2.2: Improve Customer Service

 3.2.3: Transform Business Infrastructure and Information Technology 

SURVEY TIMELINE

17. Indicate the preferred date the survey will open and close, and when reporting will be delivered by:

Open survey:* (mm/dd/yyyy)

Close survey: (mm/dd/yyyy) (If the survey will remain continuously open, this should be left blank) 

Receive results: (mm/dd/yyyy) 

18. Will this be a continuously open survey from which results will be obtained on a weekly, monthly, quarterly, semi-annual, annual, 

 or ad-hoc basis?*

(If 'Yes', select frequency):

19. What is the desired format for the final survey results? (Select all that apply)

SURVEY RESULTS

 Raw data (Excel spreadsheet with data only)

 Summary of raw data

 Analysis of data and a final report (includes summary, written and graphical depiction of results, and considerations/ 

 recommendations)
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Survey Request Form 

ADDITIONAL INFORMATION

20. Please provide any additional information about the survey project that may be beneficial: