Request for Approval

DI-4011 (Rev. 07/2018)
U.S. Department of the Interior

OMB Control. No. 1090-0011
Expiration Date 10/31/2021

REQUEST FOR APPROVAL UNDER THE
“DOI GENERIC CLEARANCE FOR THE COLLECTION OF
QUANTITATIVE FEEDBACK ON AGENCY SERVICE DELIVERY”

See Page 4 for Instructions on Completing This Form
Title of Information Collection

CADR - Agreement Seeking: Agency Decision - Participant
Purpose

Previous title: "Evaluation of Environmental Collaboration and Conflict Resolution (ECCR) Services
and Training by the DOI Office of Collaborative Action and Dispute Resolution (CADR)"
See page 2

Description of Respondents

Respondents under this ICR are individuals who have participated in an ECCR activity, such as facilitation,
mediation, and consensus building, for themselves or on behalf of a private or governmental organization. In
this Request for Approval the CADR Office is seeking customer feedback on ECCR activities from
participants, other than the case lead, in an agreement-seeking process for an agency decision.
Type of Collection (Check One)
Customer Comment Card/Complaint Form

Customer Satisfaction Survey

Focus Group

Usability Testing (e.g., Website or Software

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.
Typed Name of Requester
Signature
Date
William E. Hall 703-235-3791

Bureau ICCO
Recommend
Not Recommended
DOI PRA Program Lead
Approved
Not Approved

10/29/2018

FOR USE BY ICC PROGRAM STAFF ONLY
Signature

Date

10/29/2018
DOI Tracking Number
2018-OS-FT27

Signature

Date

signed by JEFFREY PARRILLO
10/29/2018
JEFFREY PARRILLO Digitally
Date: 2018.10.29 13:15:55 -04'00'

Page 1 of 4

PURPOSE (Continued):
The DOI Office of Collaborative Action and Dispute Resolution (CADR) is requesting approval to collect customer
feedback to evaluate the effectiveness of ECCR services provided to participants involved in DOI’s
environmental collaboration and conflict resolution processes.
ECCR is third-party assisted collaborative problem solving and conflict resolution in the context of environmental,
public lands, or natural resources issues or conflicts, including matters related to energy, transportation, and
water and land management. ECCR can be applied during policy development or planning in the context of a
rulemaking, administrative decision-making, enforcement, or litigation. The intent of ECCR is to offer a costeffective process to prevent, manage or resolve disputes and this customer feedback collection is designed to
generate information to assess the effectiveness of ECCR services and ECCR-related training and whether
those services and training are achieving the intended goals.
In order to work continuously to ensure that DOI’s programs are effective and meet its customers’ needs, DOI
obtained OMB approval of a generic clearance to collect qualitative feedback on its service delivery. As
discussed in the Supporting Statement for the approved DOI Generic Clearance for the Collection of Qualitative
Feedback on Agency Service Delivery”
(OMB Control Number: 1090-0011), qualitative feedback means information that provides useful insights on
perceptions and opinions, but are not statistical surveys that yield quantitative results that can be generalized to
the population of study. Qualitative feedback is necessary to enable the Agency to garner customer and
stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service
delivery. The information collected from our customers and stakeholders will help ensure that users have an
effective, efficient, and satisfying experience with the Agency’s programs. This feedback will provide insights into
customer or stakeholder perceptions, experiences and expectations, provide an early warning of issues with
service, or focus attention on areas where communication, training or changes in operations might improve
delivery of products or services.
Consistent with the Generic Clearance, DOI’s Office of Collaborative Action and Dispute Resolution (CADR) is
requesting approval to collect customer feedback to evaluate the effectiveness of services provided to
participants involved in DOI’s ECCR processes. The feedback the CADR Office is requesting approval to collect
is qualitative as it is not statistical, and consists of customer satisfaction, the customer’s perceived benefit from
using the CADR Office’s services, and issues or problems the CADR Office’s customers experienced.
Also consistent with the Generic Clearance, information gathered will be used only internally for general service
improvement and program management purposes and is not intended for release outside of the agency.
Although the DOI CADR does not intend to publish its findings, DOI may receive requests to release the
information (e.g., congressional inquiry, Freedom of Information Act requests). DOI will disseminate the findings
when appropriate, strictly following the DOI's "Guidelines for Ensuring the Quality of Information Disseminated to
the Public.", and will include specific discussion of the limitation of the qualitative results as discussed in the
Supporting Statement for the approved DOI Generic Clearance for the Collection of Qualitative Feedback on
Agency Service Delivery” (OMB Control Number: 1090-0011). Information gathered will not be used for the
purpose of substantially informing influential policy decisions, and the collections are voluntary, low-burden, and
non-controversial.
This ICR was developed jointly by DOI, U.S. Environmental Protection Agency (EPA) and the U.S. Army Corps of
Engineers (USACE) and already approved by OMB for use by EPA.

DI-4011 (Rev. 07/2018)
U.S. Department of the Interior

OMB Control. No. 1090-0011
Expiration Date 10/31/2021

TO ASSIST REVIEW, PLEASE PROVIDE ANSWERS TO THE FOLLOWING QUESTIONS:
Personally Identifiable Information (Please consult with your Bureau/Office Privacy Act Officer)
1. Will you collect any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)?
No
Yes If “Yes,” please consult with your Bureau/Office Privacy Act Officer.
2. If “Yes”, is the information to be collected included in records that are subject to the Privacy Act of 1974?
No
Yes
3. If applicable, has a System or Records Notice (SORN) been published?
No
Yes If “Yes,” please provide the title and FR citation below:
Title of SORN:
FR Citation for SORN
Gifts or Payments (Please refer to OMB guidance “Questions and Answers When Designing Surveys for Information Collections”)
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?
No
Yes If
“Yes”, please describe the incentive and provide a justification for the amount:

Federal Enterprise Architecture (FEA) Business Reference Model (Check only one “Line of Business” and one “Subfunction.”
Refer to OMB guidance “FEA Consolidated Reference Model Document Version 2.3”)
Line of Business
Subfunction
Line of Business
Subfunction
Community and
Social Services
Defense and
National Security
Economic
Development

(Select One)

(Select One)

(Select One)

Correctional
Activities
Disaster
Management

(Select One)

(Select One)

Education

(Select One)

Energy

(Select One)

Environmental
Management

(Select One)

General Science
and Innovation

(Select One)

Health

(Select One)

Homeland Security

(Select One)

Income Security

(Select One)

Intelligence
Operations

(Select One)

(Select One)

Law Enforcement

(Select One)

International Affairs
and Commerce
Litigation and
Judicial Activities

Natural Resources

(Select One)

Transportation

(Select One)

Workforce
Labor
Management
Burden Hour Calculation
Category of Respondent

Individuals/Households

(Select One)

Rights Management
Number of Annual
Respondents

Number of
Responses Each

Total Annual
Responses

Participation
Time

Total Burden
Hours

48

1

48

24 mins

19.2

Federal Cost: (Consult your Bureau/Office Information Collection Clearance Officer for assistance, if necessary)
The estimated annual cost to the Federal government is $ 6,000.00

, based on: (provide details below)

The estimated annual cost to the Federal government is $6,000

Sample Response to Federal Cost Question:
“If we receive 20 submissions and it takes 30 minutes to process and implement each one, then the total burden is $322.40
assuming a GS-7 step 5 is processing the submissions. Please note, however, that this custom form is a tool meant to accept
submissions in a standard format rather than through the freeform submissions that would otherwise come in by personal email.
Thus the existence of this form actually saves the government money by standardizing submissions and decreasing the workload of
processing each one.”
Page 2 of 4

DI-4011 (Rev. 07/2018)
U.S. Department of the Interior

OMB Control. No. 1090-0011
Expiration Date 10/31/2021

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the
following questions:
Selection of 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?
No
Yes If “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.

Surveys will be provided to all participants in an ECCR process and ECCR-related training. Thus,
there will be no statistical sampling.

Sample Response to Question 1 Above:
“Participants will self-select by choosing to follow the link to submit a resource. This is really no different than any website’s “Contact
Us” type of link; this submission form is only used by those who want to contribute to the toolkit. The “Submit a resource” link will be
located on the bottom of the toolkit homepage.”
Administration of the Instrument:
2.

How will you collect the information? (Check all that apply)
Web-based or other forms of Social Media

Telephone

Mail

Other:

In-person

Use of Interviewers or Facilitators:
3. Will you use interviewers or facilitators?
No

Yes
PLEASE SUBMIT SURVEY INSTRUMENT, INSTRUCTIONS, AND SCRIPTS WITH YOUR REQUEST.

Page 3 of 4

DI-4011 (Rev. 07/2018)
U.S. Department of the Interior

OMB Control. No. 1090-0011
Expiration Date 10/31/2021

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 and how you will use this information collection. 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, OMB will return the collection as improperly submitted or
they will disapprove your request.
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 Hour Calculation:
•
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. You may select only
one category.
•
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:
Selection of 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 you will collect the information. 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.
Submission of the Survey Instrument, Instructions and Scripts: You must submit a copy of the survey instrument, including all
associated instructions and scripts. The survey instrument document must show the OMB Control Number 1090-0011 and Expiration
Date 08/31/2018, along with the following Statements:
Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act
(44 U.S.C. 3501) to [insert brief justification for collection of information]. Your response is voluntary and we will not
share the results publicly. We may not conduct or sponsor and you are not required to respond to a collection of
information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey
and assigned OMB Control Number 1090-0011, which expires ##/##/####.
Estimated Burden Statement: We estimate the survey will take you ## minutes to complete, including time to read
instructions, gather information, and complete and submit the survey. You may submit comments on any aspect of
this information collection to the Information Collection Clearance Officer, [Insert Bureau], [Insert mailing address].”

Page 4 of 4