Short Form Template

REQUEST FOR APPROVAL under the Generic Clearance for NASA Education Performance Measurement and Evaluation, OMB Control Number 2700-0159, expiration XX/XX/XXXX

_____________________________________________________________________________________

1. TITLE OF INFORMATION COLLECTION: Insert

2. TYPE OF COLLECTION:

	Focus Group Protocol
	Usability Protocol
	Cognitive Interview Protocol
	Attitude/Behavior Scale
	Satisfaction Survey
	Other (Baseline Survey)

3. GENERAL OVERVIEW: Insert

4. INTRODUCTION AND PURPOSE: Insert

5. RESEARCH DESIGN OVERVIEW: Insert

6. TIMELINE: Insert

7. SAMPLING STRATEGY: Insert

8. BURDEN HOURS: Burden calculation is based on a respondent pool of individuals as follows:

Respondent Category	Statistically Adjusted Number of Respondents	Frequency of Response	Total minutes per Response	Total Response Burden in Hours
TOTAL

9. DATA CONFIDENTIALITY MEASURES: Insert

10. PERSONALLY IDENTIFIABLE INFORMATION:

    1. Is personally identifiable information (PII) collected? Yes  No

2. If yes, will any information that is collected by included in records that are subject to the Privacy Act of 1974? Yes  No

3. If yes, has an up-to-date System of Records Notice (SORN) been published?

Yes  No

APPLICABLE RECORDS:

4. Applicable System of Records Notice: SORN: NASA 10EDUA, NASA Education Program Evaluation System - http://www.nasa.gov/privacy/nasa_sorn_10EDUA.html

5. Completed surveys will be retained in accordance with NASA Records Retention Schedule 1,

Item 68D. Records will be destroyed or deleted when ten years old, or no longer needed, whichever is longer.

11. PARTICIPANT SELECTION APPROACH:

1. Does NASA Education have a respondent sampling plan?  Yes  No

If yes, please define the universe of potential respondents. If a sampling plan exists, please describe?

If no, how will NASA Education identify the potential group of respondents and how will they be selected?

12. INSTRUMENT ADMINISTRATION STRATEGY

Describe the type of Consent:  Active  Passive

1. How will the information be collected:

 Web-based or other forms of Social Media

 Telephone

 In-person

 Mail

 Other

If multiple approaches are used for a single instrument, state the projected percent of responses per approach.

2. Will interviewers or facilitators be used?  Yes  No

13. DOCUMENTS/INSTRUMENTS ACCOMPANYING THIS REQUEST:

 Consent form

 Instrument (scale, survey, etc.)

 Protocol script (Specify type________________)

 Instructions

 Other (Specify ________________)

14. GIFTS OR PAYMENT:  Yes  No  If you answer yes to this question, please describe and provide a justification for amount.

15. ANNUAL FEDERAL COST: The estimated annual cost to the Federal government is $XXXX. The cost is based on an annualized effort of xx person-hours at the evaluator’s rate of $XX/hour for administering the survey instruments, collecting and analyzing responses, and editing the survey instruments for ultimate approval through the methodological testing generic clearance with OMB Control Number 2700-0159, exp. XX/XX/XXXX.

16. CERTIFICATION STATEMENT:

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 raise issues of concern to other federal agencies.

4. The results will be made available to other federal agencies upon request, while maintaining confidentiality of the respondents.

5. The collection is targeted to the solicitation of information from respondents who have experience with the program or may have experience with the program in the future.

Name of Sponsor: ________________________

Title: ___________________________________

Email address or Phone number: ____________

Date: ____________