Draft Generic Submission Template (NRC Form 671)

NRC FORM 671

U. S. NUCLEAR REGULATORY COMMISSION

(01-2014)

REQUEST FOR APPROVAL UNDER THE
"GENERIC CLEARANCE FOR THE COLLECTION OF QUALITATIVE FEEDBACK
ON AGENCY SERVICE DELIVERY"
(OMB CONTROL NUMBER: 3150-0217)
TITLE OF INFORMATION COLLECTION:

PURPOSE:

DESCRIPTION OF RESPONDENTS:

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:
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 concerns 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.
SIGNATURE OF PROGRAM OFFICE REPRESENTATIVE:

SIGNATURE OF NRC CLEARANCE OFFICER:

To assist review, please provide answers to the following questions:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected?

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

NO

3. If Yes, has an up-to-date System of Records Notice (SORN) been published?

YES

NO

YES

NO

Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation)
provided to participants?
NRC FORM 671 (01-2014)

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NRC FORM 671

U. S. NUCLEAR REGULATORY COMMISSION

(01-2014)

REQUEST FOR APPROVAL UNDER THE
"GENERIC CLEARANCE FOR THE COLLECTION OF QUALITATIVE FEEDBACK ON
AGENCY SERVICE DELIVERY"
(OMB CONTROL NUMBER: 3150-0217) (Continued)
BURDEN HOURS:
Category of Respondents:

Number of
Respondents:

Participation Time:
(Total Minutes)

Burden:
(Total Hours)
0
0
0
0

0

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

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 responses

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

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)
WEB-BASED OR OTHER FORMS OF SOCIAL MEDIA

TELEPHONE

MAIL

IN-PERSON

OTHER:

2. Will interviewers or facilitators be used?

NRC FORM 671 (01-2014)

YES

NO

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NRC FORM 671

U. S. NUCLEAR REGULATORY COMMISSION

(01-2014)

REQUEST FOR APPROVAL UNDER THE
"GENERIC CLEARANCE FOR THE COLLECTION OF QUALITATIVE FEEDBACK
ON AGENCY SERVICE DELIVERY"
(OMB CONTROL NUMBER: 3150-0217) (Continued)
INSTRUCTIONS FOR COMPLETING NRC FORM 671

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: Provide a brief description of the targeted group or groups for this collection of
information. These groups must have experience with the program.
CERTIFICATION: Check one box. If you are requesting approval of other instruments under the generic,
you must complete a form for each instrument.
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
(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 (in minutes) 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.
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.
NRC FORM 671 (01-2014)

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