Justification for Submission

DI-4010 (Rev. 03/2021)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 01/31/2028

JUSTIFICATION FOR SUBMISSION UNDER THE
“DOI PROGRAMMATIC CLEARANCE FOR
CUSTOMER SATISFACTION SURVEYS”

See Page 5 for Instructions on Completing This Form

1. Bureau/Office
Office of the Assistant Secretary - Office of Insular Affairs

2. Date Submitted

3. Survey Title

Office of Insular Affairs Partner and Stakeholder Survey
4. Abstract (Not to exceed 150 words)

The survey is intended to gather information from Insular Area partners and stakeholders on their opinion of the Office of Insular
Affairs ability to meet its responsibilities to the Insular Communities. Specifically, the goal is to gain insight from partners and
stakeholders on their satisfaction with the Office's ability to 1) facilitate federal policy; 2) engage with respondents, and 3) effectively
address priority needs. These three responsibilities are identified in the Office’s mission to Insular communities.
The information collected will be used to develop a benchmark understanding of partners and stakeholders’ satisfaction with the
Office of Insular Affair’s activities. Collected data will be used to help Leadership develop and prioritize service and products that help
improve how the Office of Insular Affairs serves the Insular Communities, and to better carry out part of our statutory mission into the
future.

5. Bureau/Office Point-of-Contact Information
First Name

Last Name

Melissa

Braybrooks

Title

Bureau/Office

Economist

Office of Insular Affairs

Mailing Address

City

934 Broadway #300

Tacoma

Phone

202-336-2651

✔

Work
Cell

Fax

State
WA

Zip Code
98402

Email

melissa_braybrooks@ios.doi.gov
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DI-4010 (Rev. 03/2021)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 01/31/2028

6. Principal Investigation (PI) Point-of-Contact Information
First Name

Last Name

Jonathan

Dunn

Title

Bureau/Office

Deputy Director, Budget

Office of Insular Affairs

Mailing Address

City

1849 C St NW
Phone
202-219-0614

State

Washington
■

Work
Cell

Fax

DC

Zip Code

20240

Email
Jonathan_Dunn@ios.doi.gov

7. Name of Program or Office Conducting Survey
Office of Insular Affairs
8. Description of Customers and Services Provided

Customers are defined as the external territorial partners and stakeholders that the Office of Insular Affairs engages with on a regular
cadence as part of fulfilling the Department of the Interior's mission to the Insular Communities. The customer base is comprised of
territorial stakeholders and partners, who both influence the state of DOI resources through feedback and political advocacy, and who
work hand and hand with the Office to accomplish a shared mission of stability and livelihood in the Insular Areas.
Specifically, customers are defined as those in a government leadership role and/or other territorial parties who are prominent
recipients of the Office’s assistance programs.

9. Survey Dates

(mm/dd/yyyy)

(mm/dd/yyyy)
to

11/03/2025

11/19/2025

10. Type of Information Collection Instrument (Check ALL that Apply)
Intercept

Telephone

Focus Groups

Other: (Explain) email

Mail

Web-based

Comment Cards

11. Survey Development (Who assisted in survey content development statistics? Was the survey pretested? How did you
integrate improvements? Which of the six topic areas did you address?)
The survey design was constructed from a review of existing Departmental information collection that focused on customer service
satisfaction. In addition it used the Department’s approved Fast Track Likert scales as a guide for formulating non-bias survey
questions. The Department's Office of Performance and Management served as a reviewer, and suggestions for clarifying questions
to specific mission activities were incorporated.
The survey questions were modified to align with the Office of Insular Affairs stated mission as a means for tethering questions to the
Office’s actual scope of the Office, and avoid potential respondent bias or confusion on the perceived Office responsibilities. The
survey questions use ‘year to date’ to promote consistency in the rating period across respondents.
No additional pretesting was conducted.
The questions gather information on the following areas: (1) delivery and quality of information and services, (3) mission
management, and (5) Interactions with DOI personnel.

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DI-4010 (Rev. 03/2021)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 01/31/2028

12. Survey Methodology (Use as much space as needed; if necessary, include additional explanation on separate page.)
12A. Respondent Universe

The respondent universe is defined as any territorial entity responsible for serving the priorities of Insular Communities, and who rely
on partnerships with, or actions of, the Office of Insular Affairs to perform their responsibilities. This is considered the customer base
of the Office of Insular Affairs. These entities can include governmental, academic, or private parties who have a record of engaging
with the Office to impact policy or address a need.
Federal partners and stakeholders are considered out of scope of the universe.

12B. Sampling Plan/Procedure

The information collection will use a sample size of 30. The sample size will include the following:
- Ranking territorial government leadership from each of the Insular geographies. This includes 3 Presidents from the Freely
Associated States and 4 U.S. Territorial Governors. Total of 7.
- A ranking legislative branch leader from the four U.S. Territories. This includes the U.S. Congressperson from each of the four U.S.
Territories. Total of 4.
- 19 other stakeholders and partners determined by the list of largest recipients of Office of Insular Affairs assistance funding in FY24
and FY25.

12C. Instrument Administration
The information collection instrument will rely on email. The first contact will include a cover letter from the Office of Insular Affairs
explaining the survey, its importance, the deadline, and a link to the survey. The link will send respondents to a web-based app to
submit responses.
The second contact will be an email reminding respondents to complete the survey by the deadline identified in the first contact. The
second contact will only be sent to those who had not yet submitted. It will be provided 4 days following the first contact.
The third contact will be a final reminder o complete the survey by the deadline identified in the first contact. The second contact will
only be sent to those who had not yet submitted. It will be provided 10 days following the first contact.

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DI-4010 (Rev. 03/2021)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 01/31/2028

12D. Expected Response Rate and Confidence Levels

The response rate is expected to be 100%. This response rate is expected given the close working relationship that the Office has
with the respondent sample.
Confidence levels will not be explicitly calculated. The sample is derived from the Office's largest customers and therefore their
response is considered a reflection of the true population (universe).

12E. Strategies for dealing with potential non-response bias
Given the expected response rate of 100% non-response bias is expected to have no or minimal impacts on the results.

12F. Description of any pre-testing and peer review of the methods and/or instrument (recommended)

The survey design was constructed from a review of existing Departmental information collection that focused on customer service
satisfaction. The Department's approved Fast Track Liker questions were used as a guide for formulating non-bias survey questions.
The Office of Performance and Management served as a reviewer, and suggestions for clarifying questions to specific mission
activities were incorporated.
No pre-testing was conducted.

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OMB Control. No. 1040-0001
Expiration Date 01/31/2028

DI-4010 (Rev. 03/2021)
U.S. Department of the Interior

13. Burden Hours Calculations

13b. Number of
Annual Respondents

13a. Category of Respondent

13c. Number of 13d. Total Annual
Responses Each
Responses

13e. Time per
Response

13f. Total
Burden Hours

13a1. Initial Contact

13b1.

30

13c1.

1

13d1.

1

13e1.

5min

13f1.

2.5

13a2. Completion of Survey Instrument

13b2.

30

13c2.

1

13d2.

1

13e2.

10min

13f2.

5

13d3.
13f3.
60
13a3. Totals: 13b3.
1
14. 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

Community and
Social Services
Defense and
National Security
Economic
Development

(Select One)

Line of Business

Subfunction

Operational
(Select One)Defense

Correctional
Activities
Disaster
Management

(Select One)

Education

(Select One)

Energy

(Select One)

(Select One)

General Science
and Innovation

Environmental
Management

(Select One)

Health

(Select One)

Homeland Security

(Select One)

Income Security

(Select One)

Intelligence
Operations

(Select One)

Law Enforcement

(Select One)

International Affairs
and Commerce
Litigation and
Judicial Activities

Natural Resources

(Select One)

Transportation

Workforce
Management
15. Reporting Plan

7.5

(Select One)
(Select One)

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

(Select One)

Information collected will be aggregated and organized for cross-tabulation by geography, by
question, and by write in feedback. Results will be used for producing a baseline understanding of
how the office's customer's perceive, and are satisfied with, the Office's ability to perform key
mission goals. The analysis of the feedback will be used for purposes of Office planning and
identification of priorities.

16. Justification, Purpose, and Use
16A. Survey Justification and Purpose

The information is intended to measure the extent to which "customers" (i.e., territorial stakeholders
and partners) of the Department of the Interior's Office of Insular Affairs are satisfied with the Office's
activities as they relate to the Office's mission to facilitate Federal policy, communicate, and address
priority needs.
The information collected will be used to develop a benchmark understanding of partners and
stakeholders’ satisfaction with the Office of Insular Affair’s activities. Collected data will be used to
improve the service and products that the Office of Insular Affairs provides to the Insular
Communities, and to identify ideas and suggestions for improving how the Office carries out its
mission to Insular communities into the future.

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DI-4010 (Rev. 03/2021)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 01/31/2028

16B. Survey Goals

To serve as a time series indicator of the Office's ability to fulfill it's mission to Insular Communities,
and use feedback to pinpoint specific ways to modify activities to better fulfill the Office's
commitments.

16C. Utility to Managers

To provide a time series analysis of how the Office is performing its intended goal, and to use
specific feedback to modify priorities of Office resources.

16D. How will the results of the survey be analyzed and used?

Information collected will be aggregated and organized for cross-tabulation by geography, by
question, and by write in feedback. Results will be used for internal planning purposes. The
information collected will be used to develop a benchmark understanding of partners and
stakeholders’ satisfaction with the Office of Insular Affair’s activities. Collected data will be used to
improve the service and products that the Office of Insular Affairs provides to the Insular
Communities, and to identify ideas and suggestions for improving how the Office carries out its
mission to Insular communities into the future.
16E. How will the data be tabulated? How What Statistical Techniques will be used to generalize the results to the entire
customer population? How will limitations on use of data be handled? If the survey results in a lower than anticipated
response rate, how will you address this when reporting the results? (Use as much space as needed; if necessary, include
additional explanation on separate page.)

Data will be aggregated as the sum of the numeric rating relative to the total possible rating. In addition, information will
be cross-tabulated by geography, by question, and by write in feedback.
The sample is assumed to reflect the Office's largest customer base, and as such no specific steps to extrapolate to
the entire customer population will be taken.
Lower than anticipated response rates will not be explicitly addressed. However a lower than expected response rate
will be documented for Leadership, as an informal indicator of the strength (or lack of strength) of existing relationships
16F. Is this survey intended to measure a Government Performance and Results Act (GPRA) performance measure? If yes,
please include an excerpt from the appropriate document. (Use as much space as needed; if necessary, include additional
explanation on separate page.)

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DI-4010 (Rev. 03/2021)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 01/31/2028

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

1,182

, based on: (provide details below)

Total hours to prepare, send, and analyze results = 15 hours. 15 hours reflects 30min per respondent multipl
Sample Response:
“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. 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. The existence of this form actually
saves the government money by standardizing submissions and decreasing the workload of processing each one.”
18. The survey methodology presented in form DI-4010 includes a specific description of:
The respondent universe,
The sampling plan and all sampling procedures, including how respondents will be selected,
How the instrument will be administered,
Expected response rate and confidence levels,
Strategies for dealing with potential non-response bias,
A description of any pre-testing and peer review of the methods and/or the instrument is highly recommended,
The burden hours reported in the Justification include the number of burden hours associated with the initial contact of all
individuals in the sample (i.e., including refusals), if applicable, and the number of burden hours associated with individuals
expected to complete the survey instrument, and
The package is properly formatted (using MS Word) and submitted to the Office of Policy Analysis (through the Bureau/Office
Information Collection Clearance Officer).
19. The approval package includes:
A completed and signed Form DI-4010, Generic Clearance for Customer Satisfaction Surveys.
A copy of the survey instrument.
Other supporting materials, such as:
• Cover letters to accompany mail-back questionnaires,
• Introductory scripts for initial contact of respondents,
• Necessary Paperwork Reduction Act and Estimated Burden compliance language, and/or
• Follow-up letters/reminders sent to respondents.
20. Checklist for Submitting a Request to Use DOI Programmatic Clearance for Customer Satisfaction Surveys
All questions in the survey instrument are within the scope of one of the DOI Programmatic Clearance for Customer
Satisfaction Surveys topic areas.
A qualified statistician has reviewed and approved your request (see question 21A).
Your Bureau/Office Information Collection Clearance Officer receives your package for review/approval at least 75 days
prior to the first day the PI wishes to administer the survey to the public.
21. Required Certifications for Submission Under OMB Control Number 1040-0001
Certification is required to submit a collection of information for approval under the DOI Programmatic Clearance for Customer
Satisfaction Surveys. If the collection does not satisfy the requirements of the Programmatic Clearance, you should follow the
regular PRA clearance procedures described in 5 CFR 1320.
21A. Bureau/Office Statistician
Signature
Date
Recommend

Not Recommended

ANN MILLER

21B. Bureau/Office Program or Subgroup

Bureau/Office Point-of-Contact

Office of Policy Analysis

Ann Miller

Title (Please be specific)

Digitally signed by ANN MILLER
Date: 2025.08.25 15:30:42 -04'00'

Signature

ANN MILLER

Economist

08/25/25

Date
Digitally signed by ANN MILLER
Date: 2025.08.25 15:33:31 -04'00'

08/25/25

FOR PROGRAM USE ONLY

Required certifications: The information collection requested by this submission meets the requirements of OMB Control No. 1040-0001

Bureau/Office ICCO
Recommend

Signature

Not Recommended

DOI Office of Policy Analysis
Recommend
Approved

Signature

Not Recommended

DOI PRA Program Lead
Not Approved

JEFFREY PARRILLO

Date

Digitally signed by JEFFREY PARRILLO
Date: 2025.09.02 11:00:01 -04'00'

DOI Tracking No.

2025-OS-1

09/02/25
Date

signed by MELISSA BRAYBROOKS
MELISSA BRAYBROOKS Digitally
Date: 2025.08.25 15:44:06 -04'00'

Signature

JEFFREY PARRILLO

Date
Digitally signed by JEFFREY PARRILLO
Date: 2025.09.02 11:00:34 -04'00'

09/02/25
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DI-4010 (Rev. 03/2021)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 01/31/2028

Instructions for Completing Form DI-4010,
Justification for Submission Under the
“DOI Programmatic Clearance for Customer Satisfaction Surveys”
OMB Control Number 1040-0001
1.

Bureau/Office: Insert the name of the bureau/office conducting the survey.

2.

Date Submitted: Date you submit the package to the Bureau/Office Information Collection Clearance Officer (ICCO) for review.

3.

Survey Title: Insert title for the proposed survey.

4.

Abstract: Summarize the proposed study with an abstract not to exceed 150 words.

5.

Bureau/Office Point of Contact Information: Complete the bureau/office contact information. PPA will communicate with the
point of contact listed here throughout the entire approval process.

6.

Principal Investigator (PI) Conducting the Survey: Complete information about the PI who will be conducting the survey, if
different from Point of Contact listed in #4. Otherwise note: Same as #4.

7.

Name of Program Office Conducting Survey: Provide the name of the bureau program, office, or organizational unit conducting
the survey.

8.

Description of Customers and Services Provided: Provide a brief description of the customers you will survey, the services
provided by the program conducting the survey, and customers receive these services.

9.

Survey Dates: List the time-period in which you will conduct the survey, including specific starting and ending dates. The starting
date should be at least 75 days after the date you submit the package to your bureau/office Information Collection Clearance
Officer (ICCO).

10. Type of Information Collection Instrument: Check the type(s) of information collection instrument(s) you will use. If other,
please explain.
11. Survey Development: Explain how the survey was developed. With whom did you consult during the development of the survey
on content? On statistics? Did you pretest the survey? What actions did you take to improve the survey? What suggestions did
you receive for improving the survey? Which of the six topic areas will the collection address? (Note: A description of any pretesting and peer review of the methods and/or instrument is highly recommended.)
12. Survey Methodology: Explain how you will conduct the survey. Provide a description of the survey methodology including:
•
Question 12A – The respondent universe,
•
Question 12B – The sampling plan and all sampling procedures;
•
Question 12C – How the instrument will be administered;
•
Question 12D – Expected response rate and confidence levels;
•
Question 12E – Strategies for dealing with potential non-response bias; and,
•
Question 12A – Description of any pre-testing and peer review of the methods and/or instrument (recommended, but not
required).
Note: Web-based surveys are not an acceptable method of sampling a broad population. Web-based surveys must be limited to
services provided by the web site.
13. Burden Hours Calculations: Provide an estimated total of the following for each category – initial contact and completion of
survey instrument:
•
Number of annual respondents – Enter the number of unique respondents who will complete the information collection;
•
Number of responses per respondent – Enter the total number of responses per unique respondent;
•
Total annual responses – Enter the number of unique respondents multiplied by the total number of responses each;
•
Time per response – Estimate the time to complete the initial contact and the time to complete the survey instrument (in
minutes), and
•
Total burden hours –The total burden hours should account for the amount of time required to instruct the respondents in
completing the survey, and the amount of time required for the respondent to complete the survey.
14. Federal Enterprise Architecture (FEA) Business Reference Model: Using the drop-down menus provided, select ONE “Line of
Business” and ONE corresponding Subfunction that most accurately describes your information collection.
15. Reporting Plan: Provide a brief description of the reporting plan for the data you will collect.
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DI-4010 (Rev. 03/2021)
U.S. Department of the Interior

OMB Control. No. 1040-0001
Expiration Date 01/31/2028

16. Justification, Purpose and Use: For questions 16A through 16F, provide a brief justification for the survey, its purpose, goals,
and utility to managers. Specifically, describe how you will tabulate the data and what the statistical techniques you will use to
generalize the results to the entire customer population. Describe how you will use the data from the survey. Describe how you
will acknowledge any limitations related to the data, particularly in cases where we obtain a lower than anticipated response rate.
Note whether you intend the survey to measure a Government Performance and Results Act (GPRA) performance measure.
17. Federal Cost: Provide the cost estimate for the Federal government to administer the information collection, along with a
description of how you calculated the cost estimate (sample response provided). Contact your bureau/office ICCO for more
information or for assistance.
18. Survey Methodology Checklist: Carefully review each item and check each box to indicate your submission provides
the required description of each item.
19. Checklist for Submitting a Request to Use DOI Programmatic Clearance for Customer Satisfaction Surveys: Carefully
review each item and check each box to indicate your understanding and concurrence of each requirement.
20. Approval Package Content: Carefully review each item and check each box to indicate your package contains each of the
requirement elements listed.
NOTE: Your survey instrument document must show the OMB Control Number 1040-0001 and Expiration Date ##/##/###, and it
MUST include the following Statements somewhere on the instrument document (preferably at the bottom of page 1 or at the end
of the document):
Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act
(44 U.S.C. 3501) to [insert brief justification for collection of information]. Your response is voluntary and results we
will not share them 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 1040-0001.
Estimated Burden Statement: We estimate the [insert type of instrument] will take you ## minutes to complete,
including time to read instructions, gather information, and complete and submit your response. You may submit
comments on any aspect of this information collection to the Information Collection Clearance Officer, [Insert
Bureau/Office], [Insert mailing address].
21. Required Certifications: Completion of all information in this section is required before forwarding your approval
package to your bureau/office ICCO for review and processing.
Question 21A – Ensure the bureau/office statistician reviewing your information collection certifies the request satisfies
the requirements of the DOI Programmatic Clearance for Customer Satisfaction Surveys under OMB Control No. 10400001.
Question 21B – Ensure the requestor provides the requested contact information needed by the bureau/office and/or
Departmental ICCO to resolve questions or concerns.

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