Request for Approval

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 0923-0047)
TITLE OF INFORMATION COLLECTION: Post-Meeting Questionnaire of Attendees at
the 2020 Climate Ready States and Cities Initiative (CRSCI) Recipients Meeting
PURPOSE:
The purpose of the data collection request is to collect feedback on the Climate Ready States and
Cities Initiative (CRSCI) Recipients Meeting, being held on March 10th-11th.
The Climate and Health Program (CHP) provides support to state and city health departments to
address the health effects of climate change through CRSCI. The various teams of the Program –
climate science, evaluation, communications, surveillance, and program – provide technical
assistance and programmatic support to CRSCI recipients as they implement and evaluation their
climate and health adaptations.
This proposed information collection consists of a questionnaire of both multiple choice and
open-ended questions, designed to collect feedback from CRSCI recipients regarding their
satisfaction with the 2020 CRSCI Recipients Meeting. This meeting is being held to allow
recipients to collaborate with fellow recipients, federal and non-profit partners, and hear from
CDC leadership on future directions for the Program and CRSCI.

DESCRIPTION OF RESPONDENTS:
We are expecting a total attendance of 47 attendees at the 2020 CRSCI Recipients Meeting. The
online, live questionnaire (Attachment A) will be offered to all meeting attendees, consisting of
CRSCI-funded recipients and partners. All attendees who will be asked to participate in this
information collection are not Federal Employees – they are all affiliated with state, local, or
tribal governments, NGOs, or their contracted employees.

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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Digitally signed by Stephanie I.

Stephanie I. Davis -S Davis -S

Date: 2020.02.26 16:40:18 -05'00'
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
Meeting attendees (non-Federal recipients and
stakeholders)
Totals

No. of
Participation
Respondents Time
47
10/60

Burden

47

8 hours

8 hours

FEDERAL COST: The estimated annual cost to the Federal government is $155. This cost
reflects approximately 4 hours of salary (GS-12 equivalent) for one staff person to design and
implement the survey and draft an internal report of results.
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?
All meeting attendees will be surveyed; there will be no sampling plan for selecting from this
group. Participation is voluntary, and any attendee in the room during data collection is able to
answer live using the online link provided.
Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[X] Web-based or other forms of Social Media

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[ ] Telephone
[X] In-person
[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ ] Yes [X] No
The program will use Poll Everywhere® to collect online responses in real time. This
collection instrument does not collect any personally identifiable information.
Please make sure that all instruments, instructions, and scripts are submitted with the
request.
The following attachments are included:
Attachment A: 2020 CRSCI Recipients Meeting Evaluation (screenshot)
Attachment B: 2020 CRSCI Recipients Meeting Evaluation (text)
Attachment C: STARS Research/PRA Determination Form

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