Submission Form for MAPR Survey

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

TITLE OF INFORMATION COLLECTION: My AmeriCorps Portal Member Survey

PURPOSE: AmeriCorps is working on updating our applicant and member system, My AmeriCorps Portal. To help ensure the updated system meets customer needs, we are looking to survey current AmeriCorps members to gather a baseline on the current satisfaction of the My AmeriCorps Portal, learn what features they find the most beneficial and where there are opportunities for improvement. Responses will be consulted as we further build our requirements and prioritize features and functionality for the new modernized My AmeriCorps Portal

DESCRIPTION OF RESPONDENTS: We will send the survey out to current AmeriCorps members that started their terms of service in the last 12 months. This will include AmeriCorps State and National members (inclusive of Public Health AmeriCorps), NCCC members and VISTA members.

TYPE OF COLLECTION: (Check one)

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

[ ] 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:____Caitlin Simon __________________

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

Personally Identifiable Information:

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

2. If Yes, will any information that is collected be 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

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	120	5 minutes	9.9 hours
Totals

FEDERAL COST: The estimated annual cost to the Federal government is _$587.80______

Estimation of Cost to the Government
Number of responses	120
Hours per response	0.83
Total estimated hours (number of responses multiplied by hours per response)	10
Cost per hour (hourly wage)	$58.78
Annual burden (estimated hours multiplied by cost per hour)	$587.80

Note: The cost per hour is based on the mid-point base salary for NY-3, plus the 36.25% civilian personnel full fringe benefit rate from OMB memorandum M-08-13. The average cost per hour is $43.14 (average hourly rate) + $15.64 ($43.14 average hourly rate x 36.25% fringe) = $58.78/hour (rounded to the nearest penny). 

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? [x] Yes [ ] 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

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

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