IC Template

Request for Approval under the “GENERIC CLEARANCE FOR QUALITATIVE
CONSUMER EDUCATION, ENGAGEMENT, AND EXPERIENCE INFORMATION
COLLECTIONS” (OMB Control Number: 3170-XXXX)
TITLE OF INFORMATION COLLECTION:
PURPOSE:

DESCRIPTION OF RESPONDENTS:

TYPE OF COLLECTION: (Check all that apply)
[ ] In-Person Meeting
[ ] Interview
[ ] Focus Group
[ ] Social Media Poll

[ ] Qualitative Survey
[ ] Small Discussion Group
[ ] Online Discussion Forum
[ ] Other: ______________________

CERTIFICATION:
By submitting this document, the Bureau certifies the following to be true:
1. The collection is voluntary.
2. The collection is low-burden for respondents.
3. The collection is non-controversial and does not raise issues of concern to other federal
agencies.

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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

Assurances of Confidentiality:
1. Will a pledge of confidentiality be made to respondents? [ ] Yes [ ] No
2. If Yes, please cite the statue, regulation, or contractual terms supporting the pledge.

JUSTIFICATION OF SENSITIVE QUESTIONS (if applicable):

BURDEN HOURS
Category of Respondent

Number of
Respondents

Participation
Time

Burden

Totals

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

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Strategies for Selecting Respondents
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
[ ] 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?

Information Collection Procedures
Please summarize the procedures that will be used to collect data from respondents.

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

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