ACC.gov Contact Form

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 3045-0137)

TITLE OF INFORMATION COLLECTION: ACC.gov Contact Form

PURPOSE:

The general purpose of the ACC.gov contact form is to give the general public a chance to sign up to hear updates about the ACC. Because the ACC implementation team is committed to targeting the ACC to younger Americans and Americans from Justice40 zip codes, we also wish to collect zip code and a single select age range as part of the contact form so that we can ensure we are reaching the right people. Functionally, this form will test whether the site is accessible and usable by target demographics by confirming they are accessing its features.

The questions are:

• First Name

• Last Name

• Email

• Zip Code

• What is your age? (multiple choice of age ranges)

DESCRIPTION OF RESPONDENTS:

Respondents will be individuals from the general public interested in learning more or staying up to date on the ACC.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[X] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [ ] 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.

Name: Kelsey Gerber, Special Assistant, AmeriCorps

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [X] Yes [ ] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [X] Yes [ ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [X] Yes [ ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [X] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals	5000	10 seconds	14 hours
Totals	5000	10 seconds	14 hours

FEDERAL COST: The estimated annual cost to the Federal government is $360.

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 a sampling plan for selecting from this universe? [ ] Yes [X] No

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?

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[X] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [ X] No

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