Technical Assistance Evaluation

OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT
TECHNICAL ASSISTANCE EVALUATION
OMB # 1029-0114
Expires 08/31/2023

The Office of Surface Mining Reclamation and Enforcement recently provided you with technical assistance
for the project or activity listed below. Your response to this survey will assist us in evaluating and
improving our performance as required by the Government Performance and Results Act. Your response is
voluntary.
OSMRE Use Only

Project Title: ________________________________________
Agency/Organization Assisted: ________________________________________
Completion Date: __/__/____
Assistance involved: Title IV Abandoned Mined Lands Program [ ] OR Title V Regulatory Program [ ]
Name(s) of OSM Staff Who Provide Assistance: ___________________________________
Type of assistance: [ ] Technical Investigation [ ]Equipment Support [ ] Software Support
Please rate us using the following scale:
(Please circle)
Very Poor Poor
Neutral
Good Very Good

1. Please rate our timeliness:

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5

2. Please rate the quality of our assistance:

1

2

3

4

5

3. Please rate our professionalism and courtesy:

1

2

3

4

5

4. Please rate how well we met your objectives:

1

2

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5

5. Please rate your overall satisfaction:

1

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4

5

6. How may we improve our service to you, or do you have any additional comments:
To submit this evaluation form, print the form and mail, email, or fax it to:
Office of Surface Mining Reclamation and Enforcement
(Organization Name)
(Organization Address)

Email: ___________@osmre.gov
Fax:

PAPERWORK REDUCTION ACT STATEMENT
The Paperwork Reduction Act of 1995 (44 U.S.C. 3501) requires us to inform you that: Federal Agencies may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a currently valid OMB control number. This information is being collected in order to better serve you
in the future and as part of OSM's performance of its responsibilities under the Government Performance and Results Act. The obligation to respond is voluntary.
Public reporting burden for this form is estimated to average 5 minutes per response, including time for reviewing instructions, gathering and maintaining data, and
completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance
Officer, Office of Surface Mining Reclamation and Enforcement, Room 203 SIB, 1951 Constitution Ave, NW, Washington, D.C. 20240.