IC Request Template

4

Request for Information Collection (IC) Approval under

EPA’s Generic Collection of Qualitative Feedback on Agency Service Delivery

(OMB Control Number: 2010-0042, EPA ICR ID #: 2434.204) 

Instructions: [IC Justifications produced for use under the Feedback on Agency Service Delivery ICR need to describe critical factors of the specific collection that are not explained in detail in the “umbrella” ICR’s supporting statement. When complete, the justification document and any collection instruments used as part of the IC’s collection must be submitted to OMS for review. Remove all bracketed red instruction text before submitting a “clean” version of the IC Justification document to OMS’s ICR Team.]

Title of Information Collection: [Include the title for this specific collection/IC.]

EPA IC #: [ IC numbers will be included in the same sequence as the overall EPA ICR number (2434.204), but are unique to each IC submitted under the generic ICR’s umbrella. Please ask your OMS ICR desk officer to assign you an IC number.]

Short Characterization: [Provide a high-level summary of the proposed collection. Briefly address the following: type of information collection, who is submitting the information, what kind of information is being collected, and how the information will be collected. Also describe how the information will be used and what Agency need and/or program the collection will serve. The Abstract should be succinct as many of these factors are described in more detail in the following sections.]

Type of Collection (select all that apply)

☐ Survey (in print or electronic format)

☐ Widget

☐ Interview

☐ Focus Group

☐ Community/Public Meeting

☐ General Solicitation or Contest

☐ User or Observational Testing

☐ Other:

Information Collected: [Describe the information that will be collected. If the associated instrument files are screenshots of an online system and do not capture every data field collected, provide a list of all data elements.

Personally Identifiable Information:

• Is personally identifiable information (PII) collected? ☐ Yes ☐ No

• If yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? ☐ Yes ☐ No

• If yes, has an up-to-date System of Records Notice (SORN) been published? ☐ Yes ☐ No

[If personally identifiable information (PII) is going to be collected, identify the programmatic need it fills, explain any assurances of confidentiality made to respondents.]

Respondents: [List the major categories of respondents (i.e., businesses; state, Tribal or local governments; non-profit organizations; and individuals). Estimate the number of respondents in each category.]

Collection Schedule, Methodology, and Procedure: [List and briefly describe the activities a respondent must engage in to assemble, submit, and/or store the data items discussed in the previous section. Indicate how often activities are conducted and whether they are voluntary, mandatory, or required to receive or retain Agency benefits. Briefly describe the methods and technologies used and note any provisions taken to responsibly manage PII or CBI. Explain considerations taken by the Agency to minimize public burden associated with the collection – especially as they relate to respondents that are small businesses/entities.]

Statistical Methods

Does the proposed collection include a focus group, survey, or plan to employ statistical methods (i.e., using information about a sample to make inferences about a general population.)

☐ Yes ☐ No

If you are conducting a focus group or survey or plan to employ statistical methods, please answer the following questions:

The selection of your targeted respondents

• 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 and select your potential group of respondents.

Administration of the Instrument

• How will you collect the information? (Check all that apply)

☐ Web-based forms

☐ Social Media

☐ Telephone

☐ In-person

☐ Mail

☐ Other:

• Will interviewers or facilitators be used? ☐ Yes ☐ No

Uses of Resulting Data: [Describe the practical utility of the information - who will use, receive, and/or redistribute the information and for what purpose. Specifically address whether and how received information will be published or otherwise shared.]

Funding: Is the collection supporting a program carried out by EPA or EPA grantee/cooperative agreement recipient using funds from the Bipartisan Infrastructure Law (BIL) or Infrastructure Investment and Jobs Act (IIJA)? ☐ Yes ☐ No

If yes, name the overall grant/project title:

Respondent Burden & Costs: [Describe the projected public burden and costs associated with the collection. Assign per-unit burden and frequency to each significant collection action. If the collection will have respondents in both the public and private sectors, create separate estimates for each. Describe and estimate any non-labor costs (contractor costs, travel, equipment/supply costs, etc.) incurred by respondents. Provide a table that includes, at a minimum, total number of responses, total burden, and total non-labor costs. (Use of the specific table below is recommended but not necessary.) Calculations in this section should account for the full amount of activity being requested by the specific IC during the approval period assigned to the overall, “umbrella” ICR.]

Respondent Action (Add rows as necessary)	No. of Responses	Burden Per Response	Total Burden
Totals
Total Non-Labor Costs: $

Agency Activities & Costs: [List and briefly describe activities the Agency or Agency sponsored grantee will conduct to support the collection. This could include actions such as: creating/maintaining a database; recording or entering data submissions; auditing or reviewing data submissions; analyzing requests for confidentiality and providing appropriate protection; issuing a determination; reformatting and distributing data; storing data; or answering respondent questions. Estimate the Agency’s or greantee’s hourly burden associated with these tasks and estimate labor costs by applying appropriate labor rates (see the ICR’s Supporting Statement Part A for details). Also provide a description and estimate of any non-labor costs the Agency will incur. These could include contractor costs, travel, equipment/supply costs, stipends or incentives for survey or focus group participants, etc. Calculations in this section should account for the full amount of activity being requested by the specific IC during the approval period assigned to the overall, “umbrella,” ICR.]

Total Agency Costs: $

Gifts or Payments:

Are payments or gifts used to encourage participation or compensate respondents for their time or expenses? ☐ Yes ☐ No

[If the value of gifts or payments exceeds $75 per person per day, briefly explain the surrounding circumstances.]

Instrument(s): 

[List all forms or other collection instruments associated with this IC. Provide copies and/or screen shots of instruments to OMS when submitting your request.]

Point of Contact:

[Provide name and email address of an EPA point of contact for this IC. ]

Name:

Email:

Certification:

I certify the following to be true:

• Information gathered will not be used for the purpose of substantially informing influential policy decisions ^1;

• The collections are voluntary;

• The collections are low burden for respondents (based on considerations of total burden hours, total number of respondents, or burden hours per respondent) and are low cost for both the respondents and the federal government;

• The collections are non-controversial and do not raise issues of concern to other federal agencies;

• The collections are targeted to the solicitation of opinions from respondents who have experience with the EPA service/program or experience with environmental issues that the Agency may address with services/programs in the near future; and

• The collections will collect and retain personally identifiable information (PII) only to the extent and duration necessary to meet program objectives.

Name:

1 As defined in OMB and Agency Information Quality Guidelines, “influential” means that “an agency can reasonably determine that dissemination of the information will have or does have a clear and substantial impact on important public policies or important private sector decisions.”