Generic Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 1800-0011)

TITLE OF INFORMATION COLLECTION: White House Initiative on Educational Excellence for Hispanics Monthly Webinar Feedback Survey

PURPOSE:

This survey will collect information to determine if the topics are relevant, if the format is easy-to-follow, and to fix any problems encountered in gaining access to the webinar. The purpose is to use the data for the planning of future webinars. This is a voluntary survey.

DESCRIPTION OF RESPONDENTS:

Stakeholders: Individuals – non-profit leaders, teachers, practitioners, students, and staff of government officials. The webinars and survey are designed for the general public.

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: ______________________

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:_ Emmanuel G. Caudillo_______________________________________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally 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 [ ] No

3. If Applicable, has a System 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 HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals or households	150	5 minutes	12 hours
Totals	150	5 minutes	12 hours

FEDERAL COST: The estimated annual cost to the Federal government is: $0

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? [ ] Yes [X ] 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?

Administration of the Instrument

1. How 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

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