Fast Track Request Application

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 2125-0628

TITLE OF INFORMATION COLLECTION: Survey for FHWA Office of Safety Peer Exchange Participants (2015-2018).

PURPOSE: The objective of this survey is to help us improve future peer exchanges by assessing participants’ level of satisfaction with the peer exchange(s) they attended, and to investigate whether, and to what extent, they have been able to use what they learned at the peer exchange(s) to effect positive change in terms of safety-related projects, countermeasures, or other initiatives.

DESCRIPTION OF RESPONDENTS: All participants in FHWA Office of Safety peer exchanges from 2015-2018.

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:____Tara McLoughlin____________________________________________

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes (but it is voluntary) [ x] 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
Participants who attended one exhange	1160	15 mins	290 h
Participants who attended 2-5 exchanges	206	15 mins	51.5h
Totals	1366		341.5

FEDERAL COST: The estimated annual cost to the Federal government is $30,000 (this is a one-time—not annual--cost)

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?

Attached list includes all of the participants in FHWA Office of Safety peer exchanges from 2015-2018.

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.

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