Exhibit 1, 119 FW 1
Supersedes Exhibit 1, 119 FW 1, 2/3/2021
Date: February 8, 2021
Series: Information and Expression
Part 119: Surveys
In Reply Refer To:
To: Assistant Director – Management and Administration
[If applicable] Assistant Director – [add program name]
From: Chief, Policy and Regulations Branch, Division of Policy, Economics, Risk Management, and Analytics
Subject: [Title of Survey] – Request for Approval
Purpose: The purpose of this memorandum is to ask for your approval for Service employees to use official Government time and equipment to complete a survey related to [insert brief description].
Background: The purpose of the survey is to assist the [identify specific audience within USFWS] with [insert purpose].
[Details of survey/pertinent background info/all employees vs. subset]
The [online/paper-based] survey should take less than ## minutes for employees to complete. The survey, if approved, would be open for ### days. The survey has been reviewed by the [Service’s Science Integrity, Privacy Act, and Ethics Officers], who all recommend approval of the survey. Your signature below will indicate your approval.
Please contact Ms. Madonna Baucum, Policy and Regulations Branch Chief, Division of Policy, Economics, Risk Management, and Analytics (PERMA), at (703) 358-2503 if you have questions or need additional information.
[If applicable] Assistant Director – [add program name]:
Approval: ______________________________________ Date: ___________________
Disapproval: ____________________________________ Date: ___________________
Assistant Director – Management and Administration:
Approval: _____________________________________ Date: ___________________
Disapproval: __________________________________ Date: ___________________
For more information about this exhibit, contact the Policy and Regulations Branch (PRB), Division of Policy, Economics, Risk Management, and Analytics.