TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form [x] Customer Satisfaction Survey
[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group
[ ] Focus Group [ ] Other: ______________________
I certify the following to be true:
The collection is voluntary.
The collection is low-burden for respondents and low-cost for the Federal Government.
The collection is non-controversial and does not raise issues of concern to other federal agencies.
The results are not intended to be disseminated to the public.
Information gathered will not be used for the purpose of substantially informing influential policy decisions.
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:_____ Laura McCue___________________________________________
To assist review, please provide answers to the following question:
Is personally identifiable information (PII) collected? [ ] Yes [x] No
If Yes, will any information that is collected be included in records that are subject to the
Privacy Act of 1974? [ ] Yes [ ] No
If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [ x] No
Category of Respondent |
No. of Respondents |
Participation Time |
Burden Hours |
Private Sector (private school teacher) |
1 |
10 minutes |
10 minutes |
State agency (public school teachers) |
23 |
10 minutes |
3.80 (4) |
Federal agency |
17 |
10 minutes |
2.8 (3) |
Totals |
40 |
40 minutes |
7 Hours |
FEDERAL COST: The estimated annual cost to the Federal government is: ~ $40
If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:
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?
[x] 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?
We
will give the survey to all the teachers in Guam who attended the
spinner dolphin presentation in September of 2013, and received a
“Let Spinners Sleep” Student Activity Guide and
materials. The survey will be given to the entire population (40).
How will you collect the information? (Check all that apply)
[x] Web-based or other forms of Social Media
[ ] Telephone
[ ] In-person
[ x] Mail
[ ] Other, Explain
Will interviewers or facilitators be used? [ ] Yes [x ] No
Please make sure that all instruments, instructions, and scripts are submitted with the request.
File Type | application/msword |
File Title | DOCUMENTATION FOR THE GENERIC CLEARANCE |
Author | 558022 |
File Modified | 2014-06-04 |
File Created | 2014-06-04 |