Generic Clearance Submission Survey Template

Request for Approval under the “Generic Clearance for the Collection of Routine
Customer Feedback” (OMB Control Number: 1405-0193)
Expires: 04-30-2021 Estimated Burden: 5 Minutes SV-2018-0008
TITLE OF INFORMATION COLLECTION: Exam Clinic Survey

PURPOSE: The purpose is to help discern any trends in the major services we provide, and
includes an opportunity for general impressions such as cleanliness, awareness and customer
service to be shared with us.

DESCRIPTION OF RESPONDENTS: The information is collected from our adult customers
18+ years of age, those persons who use our clinic for the purposes of a medical clearance
whether it be for pre-employment or in-service purposes, separation from service physical exams
and occasionally specialty exams such as those being done for persons working in Havana, Cuba.
Our customers include Foreign Service officers, non-foreign affairs agency employees working
for the USG who need a medical clearance, eligible family members, and contractors for these
same agencies.

TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[x] Customer Satisfaction Survey
[ ] Small Discussion 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: Peter Holley

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To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [x ] No
2. If yes, will any information that is collected be included in records that are subject to the
Privacy Act of 1974? N/A
3. If yes, has an up-to-date System of Records Notice (SORN) been published? N/A
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
Federal, Contract & Civil Service Employees and
Eligible Family Members
Totals

No. of
Respondents
90 monthly

Participatio Burden
n Time
5 mins
7.5

1080 annually

5 mins

FEDERAL COST: The estimated annual cost to the Federal government is: 252.00

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90

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?
[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?
Our universe of potential respondents includes all adults 18+ who have an exam in our office,
and who have an active e-mail address. The DESCRIPTION OF RESPONDENTS gives a
profile of these persons. There is no sampling plan. All with an active e-mail address are
included in the survey request. The contact e-mail that offers the survey reads as follows:
Hello,
Now that you have completed your Medical Clearance through the Examination Clinic,
would you kindly take a moment to fill out our survey? We strive to provide you with
our excellent customer service.
All the best in your travels,
The Examination Clinic Staff
Survey link below

https://www.surveymonkey.com/s/FB2STZW
If you have any pressing issues or concerns, please don’t hesitate to contact our Clinic
Director, Peter Holley @ HolleyPR@state.gov, or via phone at 202-663-1680.

**All e-mails are sent Bcc: **

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

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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. Note: Agencies
should only collect PII to the extent necessary, and they should only retain PII for the period of
time that is necessary to achieve a specific objective.
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 per row.
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 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.

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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.
Submit all instruments, instructions, and scripts are submitted with the request.

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