Broadband USA Workshop Feedback Request Form

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number 0690-0030)

TITLE OF INFORMATION COLLECTION: BroadbandUSA Workshop Feedback

PURPOSE:

This is an evaluation form for regional workshops hosted by the National Telecommunications and Information Administration’s (NTIA) Office of Telecommunications and Information Applications. The workshops will bring together regional stakeholders for discussions around broadband deployment opportunities. Information garnered from this survey will be used to enhance NTIA’s future workshops, allowing NTIA to tailor its approach to best fit the issues relevant to its technical assistance customer base.

DESCRIPTION OF RESPONDENTS:

The respondents (~150) will have attended a day-long workshop presented by NTIA on a quarterly basis. The survey will first be used to assess the Northwest Digital Regional Workshop, which was held in March 2016. The respondents are stakeholders from state and local government, telecommunications industry professionals, and the non-profit community.

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: ______________________

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:_Aimee Meacham_____________________________

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [X] Yes [ ] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [X] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [X] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden Hours
Individuals	150	5 minutes	12.5
Totals	150	5 minutes	12.5

This survey will be distributed to accompany workshops that will be held on a quarterly basis.

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?

The respondents self-select by registering for and attending a BroadbandUSA workshop. OTIA will only contact event attendees to participate in the survey.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ X ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [X] No

Please submit all instruments, instructions, correspondences (emails, letters, etc.) to respondents, and scripts as separate documents along with this request document.

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