Request for Approval

Request for Approval under the “DOI Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

(OMB Control Number: 1090-0011)

TITLE OF INFORMATION COLLECTION: (two forms, same program, similar purpose)

Provide Feedback to BIA Tribal Climate Change Program (TCRP) – contact form + subscribe

https://docs.google.com/a/bia.gov/forms/d/e/1FAIpQLSfOVi5XbvEV3Rf347wydeC8HF9mGfHvlRNGDT_bftgJdFx3dw/viewform

Tribal Climate Resilience Resource Guide (TCR RG) Feedback Form – basic contact form only

https://docs.google.com/a/bia.gov/forms/d/e/1FAIpQLSfmEclktPPgXa5Ugc554w132iCUzGKeiwbSdC5VDJzO4U1foQ/viewform

PURPOSE: To permit users to contact the BIA TCRP Program (or report issues or needs related to the TCR RG application it maintains, same form except for subscribe/unsubscribe)

Statement up front indicates standard DOI PII warning and that there is no requirement to provide an email or phone unless seeking direct assistance. The form introduction also provides an alternative contact, if respondents prefer to contact rather than be contacted. Input is only read once upon entry by the requester and then deleted, so no PII information is maintained. If a respondent requests to subscribe/unsubscribe to the BIA Climate News subscription, the email is added/removed from the Gmail group and the subscriber status confirmed with email, which includes an unsubscribe link. Respondents can report broken links and issues without providing contact information.

DESCRIPTION OF RESPONDENTS: Federal partners; Tribal environmental and other Departmental staff and partners such as nonprofits, 95% of respondents only use the form to subscribe to BIA Climate News.

TYPE OF COLLECTION: (Check one)

[x] Customer Comment Card/Complaint Form [ ] 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:_____Rachael Noavk, Acting Climate Coordinator, BIA Tribal Climate Resilience Program, telephone: (202) 219-1652.

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ x] 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 [ x] No (email and/or phone deleted after processed)

3. If Applicable, has a System or Records Notice been published? [ ] Yes [x ] 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
BIA TCRP or TCR RG visitors	100 / year	2 minutes	3.3 hours
Totals	100		3.3 hours

FEDERAL COST: The estimated annual cost to the Federal government is ___0________, since program administrators will already have to address these comments in alternative formats if the online format did not exist. The form already exists, and requires no cost to maintain.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions: N/A

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.

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

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g., Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households; (2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g., fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time in minutes and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g., for surveys) or facilitators (e.g., for focus groups) used.

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