GenIC Request Form Template

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 0920-1050)
TITLE OF INFORMATION COLLECTION: Disaster Response Training Needs
Assessment
PURPOSE: The purpose of this activity is to identify disaster response training needs,
priorities, and existing resources of jurisdictions impacted by the 2017 Hurricanes Harvey, Irma,
and Maria in Puerto Rico, Louisiana, Florida, Georgia, and Texas.
The questionnaire will be administered online using SurveyMonkey®. A link to the
questionnaire will be emailed to public health department employees involved in disaster
response in the above jurisdictions.
The questionnaire contains demographic questions, such as role, current employment, and
number of years working in the public health field, which will help to understand the types of
roles of the people who completed the survey. The questionnaire also contains a series of Likertscale questions that ask individuals to indicate how much training they need and their level of
confidence regarding core competencies for disaster response tasks. Other questions include
training preferences such as preferred formats for trainings.
Collection of this information will help CDC develop a plan to address disaster response training
and education needs in jurisdictions impacted by the 2017 Hurricanes Harvey, Irma, and Maria
in Puerto Rico, Louisiana, Florida, Georgia, and Texas. Conducting a needs assessment will
help ensure that training and education efforts are appropriate for the target audience.
DESCRIPTION OF RESPONDENTS:
Individuals taking part in the needs assessment include public health department employees
involved in disaster response in Puerto Rico, Louisiana, Florida, Georgia, and Texas jurisdictions
impacted by the 2017 Hurricanes Harvey, Irma, and Maria.
TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[] Focus Group

[X] Customer Satisfaction Survey
[ ] Small Discussion 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.

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signed by Alisha
Alisha Etheredge Digitally
Etheredge -S
Date: 2019.02.11 12:44:35 -05'00'
-S
Name:________________________________________________

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
1000

Health Professionals
Totals

Participation
Time
20 minutes

Burden
333 hours
333 hours

FEDERAL COST: The estimated annual cost to the Federal government is $25,000. This
estimate is based on contractor support for survey development, data collection, data analysis,
and report preparation.
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?
The respondents will include public health department employees involved in disaster response
in Puerto Rico, Louisiana, Florida, Georgia, and Texas jurisdictions impacted by the 2017
Hurricanes Harvey, Irma, and Maria that are funded through the CDC cooperative agreement (1
NU1ROT000004-01-00). The technical lead for this cooperative agreement will assist with
identifying and providing email addresses for public health department employees involved in
disaster response in these jurisdictions.
Administration of the Instrument
1. How will you collect the information? (Check all that apply)

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[ 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.
Attachments:
Attachment 1 – Needs Assessment (text)
Attachment 2 – Needs Assessment (screenshots)

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