Ds-4183

U.S. Department of State

REQUEST FOR APPROVAL UNDER THE "GENERIC CLEARANCE
FOR THE COLLECTION OF ROUTINE CUSTOMER FEEDBACK"
OMB CONTROL NUMBER: 1405-0193
Title of Information Collection
Purpose

The purpose of the MED Mental Health Feedback Survey is to consistently receive feedback specifically for mental health services
that MED provides through the Directorate for Mental Health Programs. This feedback tool is in response to a Government
Accountability Office (GAO) recommendation from October 2023 in that MED is to provide a medium for specific feedback of
mental health services received overseas and domestically.

Description of Respondents

The primary audience to take this feedback survey is all Chief of Mission (CoM) personnel: U.S. Direct Hires, Eligible Family
Members (EFMs), Contractors, Locally Employed Staff (LES).
Multiple services within the Mental Health division are being individually surveyed for customer feedback. Each office has their
own section of questions.

Type of Collection: (Check one)

✘

Customer Comment Card/Complaint Form

Customer Satisfaction Survey

Usability Testing (e.g., Web site 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 (Last, First, MI)

Title

Coe, Jason, A.

Deputy Chief Medical Officer for Mental Health

Signature

DS-4183
07-2019

JASON A COE

Digitally signed by JASON A COE
Date: 2024.02.14 15:17:55 -05'00'

Date (mm-dd-yyyy)

2-14-24
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TO ASSIST REVIEW, PLEASE PROVIDE ANSWERS TO THE FOLLOWING QUESTIONS.
Personally Identifiable Information
1. Is personally identifiable information (PII) collected?

Yes

a. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974?
2. If Applicable, has a System of Records Notice been published?

✘

No

Yes

No

Yes

✘

No

Yes

✘

No

Gifts or Payments
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?
BURDEN HOURS
Category of Respondent

Number of Respondents Participation Time (Minutes)

Federal Government

14,000 annually

3

Burden Hours

700

Totals
FEDERAL COST
The estimated annual cost to the Federal government is

No specific annual cost.

IF YOU ARE CONDUCTING A FOCUS GROUP, SURVEY, OR PLAN TO EMPLOY
STATISTICAL METHODS, 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? ✘ 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.

Multiple services within the Mental Health division are being individually surveyed for customer feedback. Each office has
their own section of questions.

Administration of the Instrument
1. How will you collect the information? (Check all that apply)

✘

Web-based or other forms of Social Media
Telephone
In-person
Mail
Other, Explain

2. Will interviewers or facilitators be used?

DS-4183

Yes

✘

No

PLEASE MAKE SURE THAT ALL INSTRUMENTS, INSTRUCTIONS, AND SCRIPTS ARE SUBMITTED WITH THE REQUEST.
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U.S. Department of State

REQUEST FOR APPROVAL UNDER THE "GENERIC CLEARANCE
FOR THE COLLECTION OF ROUTINE CUSTOMER FEEDBACK"
OMB CONTROL NUMBER: 1405-0193
INSTRUCTIONS
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: 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, the collection will be returned as improperly submitted or it will be
disapproved.
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 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; or (4) Federal Government. Only one type of respondent can be
selected.
Number 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 by the participation time, and then 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.
Please make sure that all instruments, instructions, and scripts are submitted with the request.

DS-4183
07-2019

Instruction Page 1 of 1