IC Template

BUREAU OF CONSUMER FINANCIAL PROTECTION
REQUEST FOR APPROVAL UNDER THE
“GENERIC INFORMATION COLLECTION PLAN FOR THE COLLECTION OF
QUALITATIVE FEEDBACK ON THE SERVICE DELIVERY OF THE CONSUMER
FINANCIAL PROTECTION BUREAU”
(OMB Control Number: 3170-0024)
1. TITLE OF INFORMATION COLLECTION:
2. PURPOSE:
3. DESCRIPTION OF RESPONDENTS:
4. TYPE OF COLLECTION (ADMINISTRATION OF THE COLLECTION
INSTRUMENT):
a.

How will you collect the information? Check all that apply.
[
[
[
[

b.

] Web-based or other forms of Social Media
[ ] Telephone
] In-person
[ ] Mail
] Small Discussion Group
[ ] Focus Group
] Other (please explain) __________________________________

Will interviewers or facilitators be used?
[ ] Yes [ ] No [ ] Not Applicable

5. FOCUS GROUP OR SURVEY:
If you plan to conduct a focus group or survey, please provide answers to the following
questions:
a. 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 [ ] Not Applicable
b. If yes, please provide a description below. If no, please provide a description of how you
plan to identify your potential group of respondents and how you will select them.

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6. INFORMATION COLLECTION PROCEDURES:
Please summarize the procedures that will be used to collect data from respondents.
7. PERSONALLY IDENTIFIABLE INFORMATION:
a. Is personally identifiable information (PII) collected? [ ] Yes [ ] No
b. If yes, is the information that will be collected included in records that are subject to the
Privacy Act of 1974?
[ ] Yes [ ] No [ ] Not Applicable
If Yes, describe what PII will be collected and why it is needed and how it will be
used.
c. Has a System or Records Notice (SORN) been published?
[ ] Yes [ ] No [ ] Not Applicable
If yes, list the SORN title and the Federal Register (FR) citation:
Title: _________________________________________________________
__ FR _____.
d. If applicable, please provide a link to the Privacy Impact Assessment.
8. INCENTIVES:
a. Is an incentive provided to participants? [ ] Yes [ ] No
b. If yes, provide a statement justifying the use and amount of the incentive and the
amount or value of the incentive: $___________.
9. ASSURANCES OF CONFIDENTIALITY:
a. Will a pledge of confidentiality be made to respondents? [ ] Yes [ ] No
b. If yes, please cite the statue, regulation, or contractual terms supporting the pledge.
10. JUSTIFICATION OF SENSITIVE QUESTIONS (if applicable):

11. BURDEN HOURS:

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Collection of Information

[Insert rows as needed]
Totals:

Number of
Respondents

Frequency

////////////////

Number of
Annual
Responses

Average
Response
Time
(hours)
///////////////

12. FEDERAL COST: The estimated annual cost to the Federal government is $________.

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Burden
(hours)

13. CERTIFICATION:
CERTIFICATION PURSUANT TO 5 CFR 1320.9, AND THE RELATED PROVISIONS OF
5 CFR 1320.8(b)(3):
By submitting this document, the Bureau certifies the following to be true:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It uses plain, coherent, and unambiguous terminology that is understandable to
respondents;
(d) Its implementation will be consistent and compatible with current reporting and
recordkeeping practices;
(e) It indicates the retention period for recordkeeping requirements;
(f) It informs respondents of the information called for under 5 CFR 1320.8(b)(3):
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(g) It was developed by an office that has planned and allocated resources for the efficient
and effective management and use of the information to be collected;
(h) It uses effective and efficient statistical survey methodology; and
(i) It makes appropriate use of information technology.
CERTIFICATION FOR INFORMATION COLLECTIONS SUBMITTED UNDER A GENERIC
INFORMATION COLLECTION PLAN
By submitting this document, the Bureau certifies the following to be true:
• The collection is voluntary.
• The collection is low-burden for respondents.
• The collection is non-controversial and does not raise issues of concern to other Federal
agencies.
• Information gathered will not be used for the purpose of substantially informing
influential policy decisions.
• The collection is not statistically significant; the results are not intended to be
generalizable beyond the survey population.
• The results will not be used to measure regulatory compliance or for program
evaluation.

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