Memo

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

TITLE OF INFORMATION COLLECTION: Healthcare and Public Health Sector Site Assessment Risk Analysis (SARA) Tool Pilot Activity Survey Form

PURPOSE:

The National Infrastructure Protection Plan provides a framework of sixteen critical sector areas of US assets whose protection from man-made and natural disasters must be planned and prepared for. One of these is the Healthcare and Public Health (HPH) Sector for which the Critical Infrastructure Protection (CIP) program within ASPR OEM’s Division of Resilience is the designated lead. CIP is engaged in a variety of methods to protect critical healthcare and public health assets by working with the public and private members of the HPH Sector to identify, communicate, and prepare for potential risks in order to develop measures that would minimize their negative impacts.

It is essential that CIP is able to communicate formally with its Sector members in advance, to assist in the mitigation of risks before they happen. Sector partners have identified the need for an objective methodology to assist with the decision making process for resource allocation of preparedness funding. The surveys that CIP intends to distribute will:

• Be a comprehensive questionnaire to understand tool usability for sector partners. Specifically the following areas will be addressed:

1. Tool Content

2. Tool User Interface and Flow

3. Tool Reporting Content and Format

4. Tool Use-Case

5. Additional Comments

• Be used to inform the follow-up interviews with key contacts

• Become part of the feedback utilized to finalize the risk tools.

DESCRIPTION OF RESPONDENTS:

The population will be comprised of a pool of approximately 30 - 60 individuals representing a diverse group of health care organizations that are members of the HPH Sector community and membership, for each distribution cycle of the survey.

The anticipated response rate is 70 percent.

TYPE OF COLLECTION: (Check one)

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

[ ] Usability Testing (e.g., Website or Software [X] 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:___Kenneth Monahan_________________________________________

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

3. If Applicable, has a System or Records Notice 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
Healthcare and Public Health Community Members	60	20 minutes	20 hours
Totals	60	20 minutes	20 hours

FEDERAL COST: The estimated annual cost to the Federal government is ___$730.80_________

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?

ASPR CIP has provided introductory briefs on the SARA project to nationwide audiences. Through these briefs we have asked for volunteers for pilot projects and have also asked high functioning healthcare coalitions and direct care providers whether they would like to participate in our pilot project.

Administration of the Instrument

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

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

[X ] Telephone

[X ] In-person

[ ] Mail

[ ] Other, Explain

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

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

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

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)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

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