Technical Assistance (TA 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: Technical Assistance (TA) Request Form

PURPOSE:

This is a customer service evaluation form for technical assistance services delivered by the National Telecommunications and Information Administration’s (NTIA) BroadbandUSA program. BroadbandUSA provides direct, hands-on assistance to communities interested in planning and implementing broadband initiatives. Information garnered from this survey will be used to inform and guide NTIA’s technical assistance services, allowing NTIA to deliver a high-quality customer service experience through a customized technical assistance approach.

DESCRIPTION OF RESPONDENTS:

The respondents (300) will be submitting requests for technical assistance to NTIA on an ongoing basis as part of NTIA’s BroadbandUSA initiative. The respondents are stakeholders from state and local governments, telecommunications industry professionals, and the non-profit community.

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 [X] Other: Intake Form

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	300	15 minutes	75
Totals	300	15 minutes	75

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 $440

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 submitting a request for technical assistance. NTIA will only share the intake form with individuals that have expressed an interest in technical assistance services.

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.

3