Customer Satisfaction Survey Template Blank

Request for Approval under the Generic Clearance for the Collection of Routine Customer Feedback – OUANTITATIVE

(OMB Control Number: 0960-0526)

Quantitative Survey Template (Surveys for which you will perform statistical analysis) please see the attached separate file “Generic Clearance Template Explanation” for more information on completing the template below.

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)

SSA SUB-NUMBER (you will get this from the overall list we will submit after receiving OMB clearance):

DESCRIPTION OF ACTIVITY (give purpose of activity, provide specific information; i.e., date(s) of survey, number of focus groups, locations, etc.):

IF FOCUS GROUP MEMBERS WILL RECEIVE A PAYMENT, INDICATE AMOUNT: (Please note that OMB’s current limit for compensation is $40).

USE OF SURVEY RESULTS:

BURDEN HOUR COMPUTATION (Number of responses (X) estimated response time

(/60) = annual burden hours):

Number of Responses:

Estimated Response Time:

Annual Burden hours:

NAME OF CONTACT PERSON:

MAJOR OFFICE, OFFICE, DIVISION, BRANCH: