1225-0059 Generic Submission Template

CUSTOMER SATISFACTION SURVEY AND CONFERENCE EVALUATION CLEARANCE FORM

A. SUPPLEMENTAL SUPPORTING STATEMENT

A.1. Title:
A.2. Compliance with 5 CFR 1320.5: Yes _____ No _____		A.3. Assurances of confidentiality:
A.4. Federal cost: $		A.5. Requested expiration date (Month/Year): __/____
A.6. Burden Hour estimates: a. Number of Respondents: ________ a.1. % Received Electronically ____% b. Frequency: ________ c. Average Response Time: ________ d. Total Annual Burden Hours: ________		A7. Does the collection of information employ statistical methods? _______ No _______ Yes (Complete Section B and attach BLS review sheet).
A.8. Abstract:

1. SURVEYS AND EVALUATIONS EMPLOYING STATISTICAL METHODS

B.1. Describe (including a numerical estimate) the potential respondent universe and any sampling or

other respondent selection methods to be used. Data on the number of entities (e.g., establishments, State and

local government units, households, or persons) in the universe covered by the collection and in the

corresponding sample are to be provided in tabular form for the universe as a whole and for each of the

strata in the proposed sample. Indicate expected response rates for the collection as a whole. If the collection

had been conducted previously, include the actual response rate achieved during the last collection.

B.2. Describe the procedures for the collection of information including:

• Statistical methodology for stratification and sample selection,

• Estimation procedure,

• Degree of accuracy needed for the purpose described in the justification,

• Unusual problems requiring specialized sampling procedures, and

• Any use of periodic (less frequently than annual) data collection cycles to reduce burden.

B.3. Describe methods to maximize response rates and to deal with issues of non‑response. The accuracy and reliability of information collected must be shown to be adequate for intended uses. For collections based on sampling, a special justification must be provided for any collection that will not yield "reliable" data that can be generalized to the universe studied.

B.4. Describe any tests of procedures or methods to be undertaken.

B.5. Provide the name, affiliation (company, agency, or organization) and telephone number of individuals consulted on statistical aspects of the design and the name of the agency unit, contractor(s), grantee(s), or other person(s) who will actually collect and/or analyze the information for the agency.

Name	Agency/Company/Organization	Number Telephone

INSTRUCTIONS FOR COMPLETING CUSTOMER SATISFACTION SURVEY AND CONFERENCE EVALUATION CLEARANCE FORM

A.1. Title: Provide the title for the customer satisfaction or conference evaluation. This should be consistent with what appears on the collection instrument.

A.2. Compliance with 5 CFR 1320.5: If the survey or evaluation complies with 5 CFR 1320.5 (see below), mark an “X” next to “YES.” If the survey or conference evaluation does not comply with 5 CFR 1320.5, mark an “X” next to “No” and explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant‑in‑aid, or tax records for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of a statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

A.3. Assurances of confidentiality: Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy (if applicable, otherwise omit).

A.4. Federal costs: Provide estimates of annualized cost to the Federal government. For example, this could include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. These estimates should only include expenses that would not have been incurred without this collection of information.

A.5. Requested expiration date: Enter the date thru which you would like approval to conduct your customer satisfaction survey and/or conference evaluation. The date entered here should be consistent with the time you need to conduct the survey/evaluation. Please note that this date cannot extend beyond the expiration date currently assigned to OMB No. 1225-0059).

A.6. Burden Hour and burden costs estimates:

a. Enter the number of respondents (i.e., number of those to which the survey or conference evaluation is addressed).

a.1. Enter the estimated percentage of responses that will be submitted electronically. This item does not apply to conference evaluations.

b. Enter the frequency for which the survey and/or conference evaluation will be conducted. For example, if the collection is conducted on an annual basis, enter “annually.” If the collection will only be conducted once then retired, enter “one-time.” If the collection is triggered by an event (such as a customer’s experience with a product or service), enter “on occasion.” Other frequencies could include: Monthly, Bi-monthly, Semi-annually, or Bi-annually.

c. Enter the average time it would reasonably take to complete the survey or conference evaluation. Average response time includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

d. Enter the total estimated annual burden hours for the collection of information. Generally, for the purposes of customer satisfaction and conference evaluations submitted under 1225-0059, this is obtained by multiplying the average response time by the number of respondents.

A.7. Does the collection of information employ statistical methods? If the collection of information does not employ statistical methods, enter a “X” next to “NO.” If statistical methods are employed, enter an “X” next to “YES” and complete Section B -SURVEYS AND EVALUATIONS EMPLOYING STATISTICAL METHODS and attach a BLS concurrent sheet signed by the BLS reviewer.

Statistical methodology involves drawing a sample from a defined population and inferring the results obtained to the population from which the sample was drawn. The important point here is inference to the population. If inferences are not being made and the results are used only internally for planning purposes, statistical methodology is not being used. However, if the results will be made public and inferences are likely to be made, proper statistical methodology is required.

Please note, BLS review should be conducted prior to submitting for Departmental review.

A.8. Abstract: Provide a statement covering the agency’s need for the information, uses to which it will be put, and a brief description of the respondents. Other than for 1-time surveys and conference evaluations, describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology (e.g., permitting electronic submission of responses).

Note: Guidance for completing Section B., Statistical Methods, is provided within the form.

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