Request for Approval

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
Expires 09/30/2028

See Page 4 for Instructions on Completing This Form
Title of Information Collection:
National Wildlife Refuge System Customer Survey

Purpose:

The U.S. Fish and Wildlife Service (FWS) Director has initiated a review of the National Wildlife
Refuge System (NWRS) that will consider opportunities for efficiencies and improvements. Several
organizations outside the federal government work in partnership with the FWS and the NWRS.
Obtaining their feedback is important to ensure the FWS is fulfilling the NWRS purpose in a manner
that is effective, efficient, and collaborative. The review will include areas, such as how NWRS
components align with their purpose and the FWS mission, whether the current organizational
structure and staffing are meeting mission needs, if NWRS staff have the capacity to build and
maintain relationships and ability to work in partnership with local communities and wildlife
management organizations, and if there are opportunities to become more efficient and better
stewards of the NWRS’s appropriated funding.

Description of Respondents
The voluntary survey will be sent to organizations who work with the National Wildlife Refuge System to include non-governmental
organizations and state wildlife agencies.

Type of Collection: (Check One)

Comment Card/Complaint Form
Usability Testing (e.g., website or software)
Post-transaction customer surveys
(e.g., by call centers)

Focus Group
Small Discussion Group
Testing of a survey or other
collection to refine questions

■ On-line Survey
Customer satisfaction qualitative survey
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

Digital Signature/Date (Must be signed with PIV Card)

Joshua W.D. Coursey, Senior Advisor to Director (Political)

Bureau ICCO

Recommended
Not Recommended

DOI PRA Program Lead
Approved
Not Approved

JOSHUA COURSEY

Digitally signed by JOSHUA COURSEY
Date: 2026.01.06 11:41:54 -05'00'

FOR USE BY ICC PROGRAM STAFF ONLY
Digital Signature/Date (Must be signed with PIV Card)

MADONNA BAUCUM

Digitally signed by MADONNA BAUCUM
Date: 2026.01.07 09:06:51 -07'00'

DOI Tracking Number

Digital Signature/Date (Must be signed with PIV Card)

2026-FWS-FT1

signed by JEFFREY PARRILLO
JEFFREY PARRILLO Digitally
Date: 2026.01.09 11:56:17 -05'00'

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

OMB Control No. 1090-0011
Expires 09/30/2028

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
Yes If “Yes,” please consult with your Bureau/Office Privacy Act Officer.
term)? ■ No
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.”
Line of Business

(Select One)
(Select One)

Law Enforcement

(Select One)

(Select One)

(Select One)

Income Security

(Select One)

International
Affairs and Commerce
Litigation and
Judicial Activities
Transportation

(Select One)

(Select One)

(Select One)

Conservation, Marine, and Land Mgmt

Workforce Management
Burden Hour Calculation
Individuals/Households

(Select One)

(Select One)

(Select One)

Natural Resources

(Select One)

Environmental
Management
Health

(Select One)

Intelligence Operations

Subfunction

Correctional
Activities
Disaster
Management
Education

(Select One)

General Science
and Innovation
Homeland Security

Category of Respondent

Line of Business

Subfunction

Community and
Social Services
Defense and
National Security
Economic
Development
Energy

(Select One)

(Select One)

Number of Annual
Respondents

107

(Select One)

Number of
Responses Each
1

Total Annual
Responses
107

Participation
Time
15 mins

Total Burden
Hours
26.75 hours

Federal Cost: (Consult your Bureau/Office Information Collection Clearance Officer for assistance, if necessary) The
estimated annual cost to the Federal government is $ 0
, 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.”
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DI-4011 (Rev. 01/2022)
U.S. Department of the Interior

OMB Control No. 1090-0011
Expires 09/30/2028

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:
1. Do you have a customer list (or something similar) that defines the universe of potential respondents and do you have
No
a sampling plan for selecting from this universe? ■ Yes
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.
The customer list includes all state, territory, and tribal wildlife agencies/organizations; the National Wildlife Refuge Association;
the Association of Fish and Wildlife Agencies; Regional Associations of Fish and Wildlife Agencies; the National Fish and Wildlife
Foundation; the Coalition of Refuge Friends and Advocates, and other partners.

Administration of the Instrument
2. How will you collect the information? (Check all that apply)
Web-based of other forms of social media
Telephone
In-person
Mail
■ Other (explain): Link to a survey built using a Microsoft Power App.
Use of Interviewers or Facilitators:
3. Will interviewers or facilitators be used?

Yes

■

No

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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

OMB Control No. 1090-0011
Expires 09/30/2028

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 [Insert ## minutes/hours] 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], [insert email address].”

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