DI-4011, Request for Approval Under the DOI Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

DI-4011 (Rev. 01/2022)
U.S. Department of the Interior

REQUEST FOR APPROVAL UNDER THE
“DOI GENERIC CLEARANCE FOR THE COLLECTION OF
QUALITATIVE FEEDBACK ON AGENCY SERVICE DELIVERY”

OMB Control. No. 1090-0011
Expiration Date ##/##/20##

See Page 4 for Instructions on Completing This Form
Title of Information Collection
Purpose

Description of Respondents

Type of Collection (Check One)
Comment Card/Complaint Form

Focus Group

On-line Survey

Usability Testing (e.g., website or software)
Post-transaction customer surveys (e.g., by
call centers)

Small Discussion Group

Customer satisfaction qualitative survey

Testing of a survey or other
collection to refine questions

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.
Typed Name of Requester
Signature
Date

Bureau ICCO
Recommend
Not Recommended
DOI PRA Program Lead
Approved
Not Approved

FOR USE BY ICC PROGRAM STAFF ONLY
Signature
DOI Tracking Number

Signature

Date
Date
Page 1 of 4

DI-4011 (Rev. 01/2022)
U.S. Department of the Interior

OMB Control. No. 1090-0011
Expiration Date ##/##/20##

TO ASSIST REVIEW, PLEASE PROVIDE ANSWERS TO THE FOLLOWING QUESTIONS:
Personally Identifiable Information (Please consult with your Bureau/Office Privacy Act Officer)
1. Will you collect any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)?
No
Yes If “Yes,” please consult with your Bureau/Office Privacy Act Officer.
2. If “Yes”, is the information to be collected included in records that are subject to the Privacy Act of 1974?
No
Yes
3. If applicable, has a System or Records Notice (SORN) been published?
No
Yes If “Yes,” please provide the title and FR citation below:
Title of SORN:
FR Citation for SORN
Gifts or Payments (Please refer to OMB guidance “Questions and Answers When Designing Surveys for Information Collections”)
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?
No
Yes
(NOTE: In the case of in-person cognitive laboratory and usability studies, the Agency may provide stipends of up to $40. In the
case of in-person focus groups, the Agency may provide stipends of up to $75.)
If “Yes”, please describe the incentive and provide a justification for the amount:

Federal Enterprise Architecture (FEA) Business Reference Model (Check only one “Line of Business” and one “Subfunction.”
Refer to OMB guidance “FEA Consolidated Reference Model Document Version 2.3”)
Line of Business
Subfunction
Line of Business
Subfunction
Community and
Social Services
Defense and
National Security
Economic
Development

Correctional
Activities
Disaster
Management

(SelectOne)
One)
(Select
(Select
(Select One)
One)

(Select
(Select One)
One)
(SelectOne)
One)
(Select

(Select One)
One)
(Select

Education

(SelectOne)
One)
(Select

Energy

(Select
(Select One)
One)

(Select
(SelectOne)
One)

General Science
and Innovation

Environmental
Management

(Select One)
One)
(Select

Health

(Select One)
One)
(Select

Homeland Security

(Select
(SelectOne)
One)

Income Security

(Select
(Select One)
One)

Intelligence
Operations

(SelectOne)
One)
(Select

(Select
(SelectOne)
One)

Law Enforcement

(SelectOne)
One)
(Select

International Affairs
and Commerce
Litigation and
Judicial Activities

(SelectOne)
One)
(Select
Workforce
(Select One)
One)
(Select
Management
Burden Hour Calculation
Natural Resources

Category of Respondent

Transportation

Number of Annual
Respondents

Number of
Responses Each

(Select
(SelectOne)
One)

(SelectOne)
One)
(Select

Total Annual
Responses

Participation
Time

Total Burden
Hours

(Select Only One)
Individuals/Households
Federal Cost: (Consult your Bureau/Office Information Collection Clearance Officer for assistance, if necessary)
The estimated annual cost to the Federal government is $

, based on: (provide details below)

Sample Response to Federal Cost Question:
“If we receive 20 submissions and it takes 30 minutes to process and implement each one, then the total burden is $322.40
assuming a GS-7 step 5 is processing the submissions. Please note, however, that this custom form is a tool meant to accept
submissions in a standard format rather than through the freeform submissions that would otherwise come in by personal email.
Thus the existence of this form actually saves the government money by standardizing submissions and decreasing the workload of
processing each one.”
Page 2 of 4

DI-4011 (Rev. 01/2022)
U.S. Department of the Interior

OMB Control. No. 1090-0011
Expiration Date ##/##/20##

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the
following questions:
Selection of 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?
No
Yes If “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.

Sample Response to Question 1 Above:
“Participants will self-select by choosing to follow the link to submit a resource. This is really no different than any website’s “Contact
Us” type of link; this submission form is only used by those who want to contribute to the toolkit. The “Submit a resource” link will be
located on the bottom of the toolkit homepage.”
Administration of the Instrument:
2.

How will you collect the information? (Check all that apply)
Web-based or other forms of Social Media

Telephone

Mail

Other:

In-person

Use of Interviewers or Facilitators:
3. Will you use interviewers or facilitators?
No

Yes
PLEASE SUBMIT SURVEY INSTRUMENT, INSTRUCTIONS, AND SCRIPTS WITH YOUR REQUEST.

Page 3 of 4

DI-4011 (Rev. 01/2022)
U.S. Department of the Interior

OMB Control. No. 1090-0011
Expiration Date ##/##/20##

Instructions for completing Request for Approval under the
“DOI Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”
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 and how you will use this information collection. 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, OMB will return the collection as improperly submitted or
they will disapprove your request.
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 Hour Calculation:
•
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.
•
No. 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 and the participation time in minutes 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:
Selection of 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 you will collect the information. 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.
Submission of the Survey Instrument, Instructions and Scripts: You must submit a copy of the survey instrument, including all
associated instructions and scripts. The survey instrument document must show the OMB Control Number 1090-0011 and current
expiration, along with the following Statements:
Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act
(44 U.S.C. 3501 et seq.) to [insert brief justification for collection of information]. Your response is voluntary and we
will not share the results publicly. We may not conduct or sponsor and you are not required to respond to a
collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and
approved this survey and assigned OMB Control Number 1090-0011.
Estimated Burden Statement: We estimate the survey will take you ## minutes to complete, including time to
read instructions, gather information, and complete and submit the survey. You may submit comments on any
aspect of this information collection to the Information Collection Clearance Officer, [Insert Bureau], [Insert mailing
address].”

Page 4 of 4