Supporting Statement A - CBO Program FINAL 09-22-2021

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COVID-19 Community Based Vaccine Outreach Reporting Module

OMB No. 0906-0064

Revision

1. Justification

1. Circumstances of Information Collection

The Health Resources and Services Administration (HRSA) is requesting a revision of a former emergency information collection request from the Office of Management and Budget (OMB) for a data collection module to support the HRSA Health Systems Bureau (HSB) and Office of Planning, Analysis, and Evaluation (OPAE) requirement to monitor and report on funds distributed under the American Rescue Plan Act (ARP).¹ Signed into law on March 11, 2021, the ARP appropriated $250 million to HRSA to establish, expand, and sustain a public health workforce to prevent, prepare for, and respond to COVID-19. In July 2021, under the Community-Based Workforce for COVID-19 Vaccine Outreach Programs (“CBO Programs”) HRSA will be issuing funding to 141 organizations (14 for HRSA-21-136, and 127 for HRSA-21-140), including those comprising community health workers, patient navigators, and social support specialists. These organizations are responsible for educating and assisting individuals in accessing and receiving COVID-19 vaccinations, which may ultimately also include administration of COVID-19 vaccine booster shots. This includes activities such as conducting direct face-to-face outreach to community members to educate them about the vaccine, assisting individuals in making a vaccine appointment, providing resources to find convenient vaccine locations, and assisting individuals with transportation or other needs to get to a vaccination site. The program intends to address persistent health disparities by offering support and resources to vulnerable and medically underserved communities, including racial and ethnic minority groups and individuals living in areas of high social vulnerability.

HRSA is proposing a data reporting module – the Community Based Vaccine Outreach Program Reporting Module – to collect information on CBO Program funded activities. The CBO Program will collect monthly data from funded organizations. Funded organizations will provide data related to vaccination rate and equitable access to ensure that the most vulnerable populations and communities are reached; clearly identifying how the funds are being used and monitored throughout the period of performance to ensure that the target population is reached and vaccinated. Responses to some data requirements are only reported during the initial reporting cycle (e.g., the name, location, affiliation, etc. of the individual supporting community outreach), though respondents may update the data should any of that change during the duration of the reporting period.

Full proposed data elements for respondents are presented in in Table 1: HRSA will use this information to evaluate the effectiveness of the CBO Program and assist HRSA in understanding how the CBO Program funding is being used to support the Administration’s overall vaccine outreach efforts.

Table 1. Proposed Data Elements

Form number	Questionnaire number	Questionnaire item	Response options
Module landing page	N/A	1. For creating a profile on a new community outreach worker: Please use Form 1 2. For reporting on a new engagement with a community member at a COVID-19 vaccine site: Please use Form 2 3. For reporting on another (non-vaccine) type of engagement with a community member: Please use Form 3	1: Link to Form 1 2: Link to Form 2 3: Link to Form 3
Form 1 Community outreach worker profile form	OMB Number (0906-0064) Expires: XX/XX/202X Public Burden Statement: The purpose of this data collection system is to collect aggregate data on activities supported through HRSA's Community-Based Vaccine Outreach Programs (HRSA-21-136 and HRSA-21-140). HRSA will use these data to monitor the supported activities by awardees related to (1) vaccination rates and equitable access, to ensure that the most vulnerable populations and communities are reached and vaccinated throughout the period of performance. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0064 and it is valid until XX/XX/202X. Public reporting burden for this collection of information is estimated to average .27 hours per response, including the time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected]. Instructions: The information that you provide in this form is very important and helps us (HRSA) understand how job opportunities were created through government funding from our agency, and how the jobs that were created from this funding helped to get more people vaccinated for COVID-19. There are a total of 29 questions in this form, and we ask that you answer everything honestly and to the best of your ability. Thank you very much in advance for your help in providing this information!
	1-1	We collect the information that follows in this form with a unique identifier number that only you and your employer know so that your responses to our questions will not be associated with your name or any information that can be used to identify you. This keeps your responses to this survey anonymous.	I understand and agree
	1-2	Please provide the unique identifier assigned to you as a community outreach worker (by your employer).	Unique identifier (providing anonymity to individuals)
	1-3	What is the name of your employer (the community-based organization supported by HRSA) that you work for as a community outreach worker?	Text entry
	1-4	We're going to start by asking you some questions about yourself. Your responses will not be associated with your name or any information that can be used to identify you. Please provide the 5-digit ZIP code where you live.	Text entry: 5-digit ZIP code
	1-5	Do you own the home where you live (check one)?	Yes No
	1-6	How many people live in your household, including yourself (check one)?	0 1 2 3 4 5 6 If more than 6, please enter the number of people in your household below.
	1-7	Do you live in the same community where you will work for this job as a community outreach worker (check one)?	Yes No
	1-8	Please list all the ZIP codes where you know that you'll be working in this role (as a community outreach worker). Please put only one ZIP code in a box. If you don't know the answer to this yet, type "NA" in the first box.	5-digit ZIP codes [in 10 text boxes]
	1-9	Have you been fully vaccinated against COVID-19 (check one)?	Yes, I am already fully vaccinated against COVID-19 No - but I have gotten 1 shot out of the 2 needed, and I intend to get the second one soon No - but I have gotten 1 shot out of the 2 needed, however I do NOT intend to get the second shot soon No - I have not gotten a COVID-19 vaccine but I do plan to No - I have not gotten a COVID-19 vaccine and I do not intend to I prefer not to answer
	1-10	If you have had one or more shots of the COVID-19 vaccine, please list the vaccine that you received.	I have not gotten a COVID-19 vaccine I have had 1 or 2 shots of the Pfizer COVID-19 vaccine I have had 1 or 2 shots of the Moderna COVID-19 vaccine I got the Johnson & Johnson (Janssen) vaccine I got a COVID-19 vaccine but I don't know what type it was I prefer not to answer
	1-11	How old are you?	Text entry
	1-12	Please check ALL of the following that you identify as:	Male Female Transgender Genderqueer, gender nonconforming, or nonbinary Agender I prefer not to answer Something else not listed here (please specify):
	1-13	Please check ALL of the following that you identify as:	Straight or heterosexual Lesbian or gay Bisexual Queer or pansexual Questioning Something else Don’t know I prefer not to answer Something else not listed here (please specify):
	1-14	Please check ALL of the following that you identify as:	White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander I prefer not to answer
	1-15	Do you identify as Hispanic or Latino/Latina/Latinx (check one)?	Yes No I prefer not to answer
	1-16	Do you speak more than one language fluently?	No Yes. If your answer is "Yes" then please list all languages other than English that you speak fluently below:
	1-17	What is your marital status (check one)?	Never married Married In a long-term partnership that is not marriage Separated Divorced Widowed I prefer not to answer
	1-18	What is highest level of school/education that you have successfully completed (check one)?	Less than a GED or high school diploma Completed a GED or high school diploma Completed some college Earned an Associate’s degree Earned a bachelor’s degree Earned a post undergraduate or professional certificate (non-degree) Earned a post undergraduate or professional degree I prefer not to answer
	1-19	Now we are going to switch gears a bit, and just talk about your job as a community outreach worker. How many hours do you work in a usual/typical 7-day week - specifically in this job (as a community outreach worker)? If the hours you work can vary week to week, then enter an average number of weekly hours.	Text entry
	1-20	In addition to this job (as a community outreach worker), do you have any other jobs?	Yes No
	1-21	Do you get paid by the hour for this job as a community outreach worker?	No - I get paid an annual salary, not by an hourly wage No - I do not get paid at all for this job - this is a volunteer position Yes - I get an hourly wage for this job. Please also enter your hourly wage/rate below. Only include your pay for this job as a community outreach worker. Do not enter anything here if you get an annual salary. Please leave the dollar sign ($) out of your answer and just enter the number (for example, enter 5 if you get paid $5 per hour). You can use a decimal if needed (for example 7.50 for $7.50 per hour).
	1-22	Do you get paid by an annual salary for this job as a community outreach worker? If you get paid by the hour instead of with a salary, select "No."	No - I get paid by an hourly wage, not an annual salary No - I do not get paid at all for this job - this is a volunteer position Yes - I get an annual salary for this job. Please also enter your annual salary below. Only include your pay for this job as a community outreach worker. Do not enter anything here if you get an hourly wage. Please leave the dollar sign ($) and commas (,) out of your answer and just enter the number (for example enter 1000 if you get paid $1,000 per year). Please don't use any decimals - round to the nearest dollar amount if necessary.
	1-23	What is your annual total household income - including all sources of income for yourself AND for any spouse or long-term partner in the home? Please leave the dollar sign ($) and commas (,) out of your answer and just enter the number (for example enter 1000 for $1,000).	Text entry
	1-24	Before taking this job, did you have any past experience with community outreach work - including work in community-based outreach and education, public health, or work in a related field?	No Yes I have past experience with community outreach work. Please list all related job titles you have had in community-based outreach and education, public health, or related fields. For example, this could include working as a COVID-19 contact tracer, collecting Census information from households, working as a community health worker or health educator, etc. Please list all of your similar past experiences/job positions in this box. Only your past job titles are needed here (for example, community health worker), not full descriptions.
	1-25	For THIS job as a community outreach worker, do you plan to use any information/resources/tools provided by the Federal Government (CDC, HHS, HRSA, NIH, etc.) or other government-supported COVID-19 vaccine outreach programs?	No Not sure Yes I plan to use government-supported tools, materials, and resources for this job. Please list all of the items you plan to use below.
	1-26	For THIS job as a community outreach worker, please select ALL of the following activities/resources that you plan to use as part of your regular job duties (select all that apply):	Constructing and/or monitoring an interactive community website, blog, or related web-based tool designed to promote COVID-19 vaccine outreach, education, and accessibility Constructing and/or monitoring an interactive social media site (or related campaign) designed to promote COVID-19 vaccine outreach, education, and accessibility. Educational and/or informational fliers on COVID-19 vaccine outreach and accessibility Door-to-door outreach Visiting housing or apartment complexes Other form of in-person interaction Telephone Text messages Email Mail Webinar Training session Virtual town hall Interactive website Radio spot TV spot Billboards and/or other posters/signs around the community Door hangers Flyers Focus groups Community fair/events Visiting a community-based recreation center Visiting a church, temple, or other religious site Visiting a park or similar public space Visiting a local school, college, or a community learning center Visiting a local library or other public building Visiting an LGBTQ+ community/resource center Visiting a community/resource center for a specific population of people sharing a common background (Italian Americans club, a meeting place for Spanish-speakers, etc.) Visiting a facility helping unhoused people (homeless shelter, etc.) Providing outreach and education in a language other than English I don't plan to use any of these activities/tools/resources listed here Something else not listed here (please specify):
	1-27	If you plan to follow-up one or more additional times with an unvaccinated community member, after having previously interacted with them, please select ALL of the following methods you plan to use to do this:	I don't plan to follow up with community members I've interacted with before Same choices as 1-26
	1-28	If you plan to directly assist community members with identifying their nearest vaccine location site(s), please select ALL of the following methods you plan to use to do this:	I don't plan to assist community members with identifying their nearest vaccine location site(s) Same choices as 1-26
	1-29	If you plan to directly assist community members with obtaining transportation to a vaccine location site(s), please select ALL of the following methods you plan to use to do this:	I don't plan to assist community members in obtaining transportation to a vaccine location site(s) Same choices as 1-26
Form 2 Community member profile form – COVID-19 vaccine site	OMB Number (0906-0064) Expires: XX/XX/202X Public Burden Statement: The purpose of this data collection system is to collect aggregate data on activities supported through HRSA's Community-Based Vaccine Outreach Programs (HRSA-21-136 and HRSA-21-140). HRSA will use these data to monitor the supported activities by awardees related to (1) vaccination rates and equitable access, to ensure that the most vulnerable populations and communities are reached and vaccinated throughout the period of performance. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0064 and it is valid until XX/XX/202X. Public reporting burden for this collection of information is estimated to average .12 hours per response, including the time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected]. Instructions: The information that you collect about the people you serve at your vaccine site is very important and helps HRSA better understand how to get more people vaccinated for COVID-19. This information, and the work you that are doing, can help to save lives! There are a total of 14 questions in this form. The first 6 questions (Section A) you should answer. The next 8 questions (Section B) the community member you are interacting with should answer. You can help by asking the Section B questions and entering the community member’s answers for them if you or they prefer. We just ask that you make sure everything is filled out as honestly and as completely as possible. Thank you very much in advance for your help in providing this important information!
	2-1	Section A. This section is for you (the community outreach worker) to fill out when you interact with a member of the community at your vaccine site. Please provide the unique identifier assigned to you as a community outreach worker (by your employer).	Text entry
	2-2	Please provide the unique identifier assigned to the community member with whom you are now interacting.	Text entry
	2-3	List the ZIP code where the community member lives and/or is being contacted.	5-digit ZIP code
	2-4	Please provide the date of your interaction with this community member. Use the following format for your answer: MM/DD/YYYY.	Date: MM/DD/YYYY
	2-5	Is this the first time that this community member has been contacted?	Yes No
	2-6	Which COVID-19 vaccine is being given to this individual today:	The first shot of the Pfizer COVID-19 vaccine The second shot of the Pfizer COVID-19 vaccine The first shot of the Moderna COVID-19 vaccine The second shot of the Moderna COVID-19 vaccine The (one shot) Johnson & Johnson (Janssen) vaccine Something else, not sure, or not yet determined
	2-7	Section B. These are questions that the community member should answer themselves. However, you can help them by asking these questions and entering the answers they tell you into the form for them if it is easier. Please list ALL of the reasons why you may have hesitated or delayed getting a COVID-19 vaccine before today.	None - I didn't have any concerns making me hesitate to get a COVID-19 vaccine I did not have transportation/a way to actually get to a vaccine site (no ride) I did not have time to get to a vaccine site because I had to work at my job(s) I did not have time to get to a vaccine site because of my child care or other family commitments (busy with kids or family) Information I learned about the vaccine scared me - but I later learned that this was wrong information I was concerned about the vaccine’s potential side effects I did not think I was at high-risk for getting COVID-19 (the coronavirus /illness) I was not scared about getting COVID-19 (the coronavirus/illness) and therefore I didn't think I really needed the vaccine I don't really trust doctors and/or the health care system I don't really trust vaccines in general and I don't usually get any vaccines This (COVID-19) vaccine in particular scares me, although I've gotten other types of vaccines before (like tetanus or flu shots) I did not know where or how to get the vaccine I did not know that the vaccine would be free (at no cost to me) I don’t know why I was hesitant to get the vaccine before Something else made me wait until today (please specify what that is):
	2-8	How old are you?	Text entry
	2-9	Please check ALL of the following that you identify as:	Male Female Transgender Genderqueer, gender nonconforming, or nonbinary Agender I prefer not to answer Something else not listed here (please specify):
	2-10	Please check ALL of the following that you identify as:	Straight or heterosexual Lesbian or gay Bisexual Queer or pansexual Questioning Something else Don’t know I prefer not to answer Something else not listed here (please specify):
	2-11	Please check ALL of the following that you identify as:	White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander I prefer not to answer
	2-12	Do you identify as Hispanic or Latino/Latina/Latinx (check one)?	Yes No I prefer not to answer
	2-13	Is English your first/primary language (the main one you speak)?	Yes If your answer is "No" then please list the first/main language other than English that you usually use below:
	2-14	If you are getting the COVID-19 vaccine today as a result of someone reaching out to you with information, sources of information made the difference for you to get vaccinated today?	I saw a community website, blog, or web-based tool about COVID-19 vaccines I saw a social media site (or related campaign) about COVID-19 vaccines I received educational and/or informational fliers about COVID-19 vaccines Someone came to my home for door-to-door outreach Someone came to my housing or apartment complex to give information Some other health worker provided my information I received a telephone call (or calls) I received text messages I received email I received mail I joined a webinar I joined a training session I joined a virtual town hall I heard a radio spot I saw a TV spot I saw billboards or other types posters/signs around my community Someone left information hanging on my door knob I received a flyer I was in a focus group I attended and got information at a community fair or event I was at and got information from a community-based recreation center I was at and got information from a church, temple, or other religious site I was at and got information from a local school, college, or a community learning center I was at and got information from a local library or other public building I was at and got information from an LGBTQ+ community/resource center I was at and got information from a community/resource center for a population of people sharing a common background with me (Italian Americans club, a meeting place for Spanish-speakers, etc.) I was at and got information from a facility helping unhoused people (homeless shelter, etc.) I didn't get information from any of the things listed here I got information from some other source not listed here (please specify):
Form 3 Community member profile form – general outreach/education	OMB Number (0906-0064) Expires: XX/XX/202X Public Burden Statement: The purpose of this data collection system is to collect aggregate data on activities supported through HRSA's Community-Based Vaccine Outreach Programs (HRSA-21-136 and HRSA-21-140). HRSA will use these data to monitor the supported activities by awardees related to (1) vaccination rates and equitable access, to ensure that the most vulnerable populations and communities are reached and vaccinated throughout the period of performance. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0064 and it is valid until XX/XX/202X. Public reporting burden for this collection of information is estimated to average .12 hours per response, including the time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected]. Instructions: The information that you collect about the people you serve is very important and helps HRSA better understand how to get more people vaccinated for COVID-19. This information, and the work you that are doing, can help to save lives! There are a total of 13 questions in this form. We ask that you make sure everything is filled out as honestly and as completely as possible. Thank you very much in advance for your help in providing this important information!
	3-1	Please provide the unique identifier assigned to you as a community outreach worker (by your employer).	Text entry
	3-2	How many community members are attending/receiving the specific intervention that you're reporting on here?	Text entry
	3-3	List the ZIP code where this outreach is occurring.	This outreach covers too big an area to enter a single ZIP code - such as a tweet or webinar Otherwise specify the ZIP code here:
	3-4	Where is this intervention that you're reporting on here occurring? Please list the city and state (for example: "Chicago, IL").	Text entry
	3-5	If the neighborhood this intervention is occurring in has a more specific name than Question 3 provides, please list the name of the neighborhood here (for example: "The Bronx in New York, NY").	Text entry
	3-6	Please provide the date of this specific outreach effort. Use the following format for your answer: MM/DD/YYYY.	MM/DD/YYYY
	3-7	What type of location is this outreach occurring at?	No physical location – the outreach/assistance was about providing transportation/assistance getting to a vaccine site for a community member(s) No physical location – for example, for outreach using the internet or social media Community recreation center (e.g., public rec center, YMCA) A community/resource center for a population of people sharing a common background (Italian Americans club, a meeting place for Spanish-speakers, etc.) LGBTQ+ community center Other type of community center School, college, community college, or trade school Other community-based learning center Job training or placement center Youth center Facility for unhoused people (homeless shelters) Tribal program/site Public assistance centers Church, temple, or other faith-based/religious site Homes in a neighborhood A housing or apartment complex Hospital Community health center Doctor’s office or similar setting Pharmacy Health department Other official or government/public building (for example a library, town hall, or post office) Park or other/similar public space Neighborhood convenience store or bodega Other type of store or shopping mall Local/neighborhood small business site A hair salon, barber shops, or nail salon Some other type of site (please specify):
	3-8	Is this the first time that this community member or group of community members has been contacted? If this is a group and it is the first time for most participants to be contacted, select “Yes.”	Yes No
	3-9	Is this outreach occurring in the English language?	Yes If your answer is "No" (the outreach is not in English), then please list all other languages other than English that are being used below. If this outreach is occurring in English AND in another language, then please check BOTH boxes and ALSO list all other languages other than English that are being used below:
	3-10	Which of the following methods are being used for this outreach effort:	A vaccine delivery site (e.g., a pop-up site to deliver COVID-19 vaccines) A community website, blog, or web-based tool about COVID-19 vaccines (including where/when to get them) A social media site (or related campaign) about COVID-19 vaccines (including where/when to get them) Educational and/or informational fliers about COVID-19 vaccines (including where/when to get them) General information on COVID-19 vaccines (how they work, how effective they are, how safe they are) but NOT information on where/when to get them Door-to-door outreach Other form of in-person interaction not listed here A telephone call (or calls) Text message(s) Email(s) Mail A webinar A training session A virtual town hall A radio spot A TV spot Billboards or other types of posters/signs around the community Door hangers Flyers Focus group(s) A community fair or event Visiting a community-based recreation center Visiting a church, temple, or other religious site/building Visiting a local school, college, or a community learning center Visiting a local library or other public building (for example a town hall or post office) Visiting an LGBTQ+ community/resource center Visiting a community/resource center for a population of people sharing a common background with me (Italian Americans club, a meeting place for Spanish-speakers, etc.) Visiting a facility helping unhoused people (homeless shelter, etc.)
	3-11	If possible to determine, how many community members receiving this outreach/intervention today say that they agree to receive a COVID-19 vaccine as a result of your efforts/intervention?	This cannot be determined This can be determined (please specify the number of people who agree to get vaccinated):
	3-12	Please select ALL of the characteristics below that describe the community member(s) present for/receiving/participating in this intervention today.	Children (people aged 0-11 years old) Adolescents/teenagers (people aged 12-17 years old) Young adults (people aged 18-29 years old) Adults (people aged 30-64 years old) Seniors (people 65 years old and above) Men Women Individuals who identify as non-binary or transgender Individuals self-identified as LGBTQ+ Individuals self-identified as African American or Black Individuals self-identified as American Indian or Alaska Native Individuals self-identified as Asian Individuals self-identified as Native Hawaiian or Other Pacific Islander Individuals self-identified as white Individuals self-identified as Hispanic/Latino People who are bilingual/multilingual or for whom English is not their primary language Members of a specific faith or religious group If members of a specific faith or religious group participated, please list the faith or religious group(s) of participants (please specify):
	3-13	If this intervention was specifically geared to a specific population of community members (for example, this was an event at a high school specifically for teenagers, or it was specifically for the LGBTQ+ community at an LGBTQ+ resource center), then please select ALL of the characteristics below that describe who this outreach/intervention was intended for.	Same choices as 3-12
Form 4 Community member profile form – booster vaccines	OMB Number (0906-0064) Expires: XX/XX/202X Public Burden Statement: The purpose of this data collection system is to collect aggregate data on activities supported through HRSA's Community-Based Vaccine Outreach Programs (HRSA-21-136 and HRSA-21-140). HRSA will use these data to monitor the supported activities by awardees related to (1) vaccination rates and equitable access, to ensure that the most vulnerable populations and communities are reached and vaccinated throughout the period of performance. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0064 and it is valid until XX/XX/202X. Public reporting burden for this collection of information is estimated to average .12 hours per response, including the time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected]. Instructions: The information that you collect about the people you serve is very important and helps HRSA better understand how to get more people vaccinated for COVID-19. This information, and the work you that are doing, can help to save lives! There are a total of 13 questions in this form. We ask that you make sure everything is filled out as honestly and as completely as possible. Thank you very much in advance for your help in providing this important information!
	4-1	Section A. This section is for you (the community outreach worker) to fill out when you interact with a member of the community at your vaccine site. Please provide the unique identifier assigned to you as a community outreach worker (by your employer).	Text entry
	4-2	Please provide the unique identifier assigned to the community member with whom you are now interacting.	Text entry
	4-3	List the ZIP code where the community member lives and/or is being contacted.	5-digit ZIP code
	4-4	Please provide the date of your interaction with this community member. Use the following format for your answer: MM/DD/YYYY.	Date: MM/DD/YYYY
	4-5	Is this the first time that this community member has been contacted?	Yes No
	4-6	Which COVID-19 vaccine did you previously receive, before today’s booster shot:	A BOOSTER shot of the Pfizer COVID-19 vaccine A BOOSTER shot of the Moderna COVID-19 vaccine A BOOSTER Johnson & Johnson (Janssen) vaccine Something else, or I’m not sure
	4-7	Section B. These are questions that the community member should answer themselves. However, you can help them by asking these questions and entering the answers they tell you into the form for them if it is easier. Please list ALL of the reasons why you may have hesitated or delayed getting a COVID-19 vaccine before today.	A BOOSTER shot of the Pfizer COVID-19 vaccine A BOOSTER shot of the Moderna COVID-19 vaccine A BOOSTER Johnson & Johnson (Janssen) vaccine Something else, not sure, or not yet determined
	4-8	Please list the date that you got your last COVID-19 vaccine shot. Make your best guess if you can’t remember exactly. If you got the Pfizer or Moderna vaccine, list the day that you got your second shot.	Date: MM/DD/YYYY
	4-9	How old are you?	Text entry
	4-10	Please check ALL of the following that you identify as:	Male Female Transgender Genderqueer, gender nonconforming, or nonbinary Agender I prefer not to answer Something else not listed here (please specify):
	4-11	Please check ALL of the following that you identify as:	Straight or heterosexual Lesbian or gay Bisexual Queer or pansexual Questioning Something else Don’t know I prefer not to answer Something else not listed here (please specify):
	4-12	Please check ALL of the following that you identify as:	White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander I prefer not to answer
	4-13	Do you identify as Hispanic or Latino/Latina/Latinx (check one)?	Yes No I prefer not to answer
	4-14	Is English your first/primary language (the main one you speak)?	Yes If your answer is "No" then please list the first/main language other than English that you usually use below:

2. Purpose and Use of Information

Approval of the CBO data collection request is urgent and time-sensitive to meet the requirements of the ARP and OMB Memo 21-20, and to ensure that HRSA is adequately supporting the Administration’s priority effort to increase COVID-19 vaccination rates. Because of the urgent nature of the COVID-19 pandemic response, combined with the quick disbursement of and the short-term duration of this funding, it is important for HRSA to obtain data as quickly as possible as of the date of this request. The data will allow HRSA to ensure CBO Program recipients are meeting the terms and conditions of their funding, while providing HRSA with information on the effectiveness of funds distributed through this program.

The CBO Program monthly progress reports will include both quantitative data and brief narratives to capture project progress on the hiring process, the number of community outreach workers hired to date, and the number of individuals hired from the communities served by this funding. Award recipients additionally will be asked to provide the number of individuals directly assisted, and/or number of individuals that received vaccine outreach and education;

• Whether program funds are being spent for their intended purposes;

• Where health workforce outreach supported by these funds is occurring;

• Number, location, and demographics of individuals included in the outreach; and

• Whether or not individuals included in the outreach ultimately chose to receive the COVID-19 vaccine

3. Use of Improved Information Technology

The CBO Program will collect only the minimum information necessary for the purposes of program monitoring and reporting, but will need to collect some data to ensure that this investment in building a public health workforce meaningfully promotes health equity and successfully vaccinates at-risk people against COVID-19. To find a balance between collecting rich data and minimizing reporting burden, HRSA has developed three data collection tools (within the single Program Reporting Module) which use Survey Monkey to make reporting relatively fast and easy for CBO program awardees to use and essentially limits the need for progress reporting by awardees to only brief narratives.

• Community outreach worker profile form: Hyperlink

• This form of the module is the most labor intensive of the three – there are 29 questions which take ~16 minutes to complete – but it only needs to be filled out once by each community outreach worker.

• Community member profile form – COVID-19 vaccine site: Hyperlink

• This form of the module only needs to be filled out once for a community member, it can be filled out by the community outreach worker, and has 14 questions which take ~7 minutes to complete.

• Community member profile form – general outreach/education: Hyperlink

• This form of the module only needs to be filled out once for a community member, it can be filled out by the community outreach worker, and has 13 questions which take ~7 minutes to complete.

4. Efforts to Identify Duplication

Data required to evaluate and monitor the implementation of the CBO Program, such as information on the use of funds, organization site locations, and number of people included in the outreach activities are not available elsewhere.

5. Involvement of Small Entities

The information being requested has been held to the absolute minimum required for the intended use of the data.

6. Consequences if Information Collected Less Frequently

Given the urgency to increase vaccination rates, without monthly reporting on the use of funds and number of individuals included in outreach activities and their ultimate decision of whether or not to get vaccinated, HRSA will not be able to carry out its responsibility to oversee compliance with the intent of Congressional appropriations in a timely manner. Moreover, without monthly reporting, HRSA will not be able to course correct should any gaps or limitations in program implementation be identified.

7. Consistency with Guidelines in 5 CFR 1320.5(d)(2)

The data will be collected in a manner fully consistent with the guidelines in 5 CFR 1320.5(d)(2).

8. Consultation Outside the Agency

A 60-day Notice published in the Federal Register, 86 Fed. Reg. 45739 (August 16, 202). There were no public comments.

9. Remuneration of Respondents

Respondents will not be remunerated.

10. Assurance of Confidentiality

The CBO Program does not require any information that could identify individual participants. Aggregate data on the number of individuals who received outreach will be collected, but personally identifiable information will not be collected. Unique identifiers, not traceable to any individuals, will be used to generate program data on outreach activities at the individual level.

11. Questions of a Sensitive Nature

The CBO Program does not collect confidential or protected information. There are no questions of a sensitive nature.

12. Estimates of Annualized Hour Burden

The CBO Program Data Collection Module is a new data module used to collect the minimum data necessary to monitor and support the proper and effective use of funds. Burden estimates for respondents are presented in in Table 2: Estimated Burden of Responses over the Entire Reporting Period. The total estimated burden for CBO Program respondents is 934,133 hours over one year. To assess the burden, HRSA gathered data on the anticipated number of respondents and responses based on internal data and assessed average burden hours based on input gathered from other data collection activities fielded by HRSA during the COVID-19 PHE. More accurate counts of funded providers will be collected and reported once they are available. It is important to consider that the funding from the CBO programs are creating the job positions for the community outreach workers who will be completing the CBO Program Data Collection Module, and the expended effort to collect this data is considered to be part of the primary role of these job positions.

Table 2. Estimated Burden of Responses over the Entire Reporting Period

Form Name	Number of unique organizations funded through the two programs	Number of Respondents	Number of Responses per Respondent	Total Responses	Average Burden per Response (in hours)	Total Burden Hours
Community outreach worker profile form	10 cooperative agreement awards for HRSA-21-136 and 121 grant awards for HRSA-21-136	Total number of Community outreach workers deployed through the work of the two programs	One response per respondent	Reported once across the duration of the programs (the period of performance for HRSA-21-136 is 6 months, and for HRSA-21-140 is 12 months)	Sampled response times of approximately 15 minutes per response	Total hours spent on responses for all funded organizations over a 2-year period
	131	3,000 (est.)	1	3,000	0.27 hours	800

Form Name	Number of Community Outreach Workers	Number of Respondents Over the Period of the Programs	Number of Responses per Respondent	Total Responses	Average Burden per Response (in hours)	Total Burden Hours
Vaccine-site data – outreach to community members form	Number of community outreach workers deployed for 6 months (HRSA-21-136) or 12 months (HRSA-21-140) of support	Number of community members in contact with community outreach workers	One response per respondent or less (e.g., one response from the audience of a group outreach event)	Reported once across the duration of the programs (the period of performance for HRSA-21-136 is 6 months, and for HRSA-21-140 is 12 months)	Sampled response times of approximately 6 minutes per response	Total hours spent on responses for all funded organizations over a 2-year period
	3,000 (est.)	4,000,000 (est.)	1	4,000,000	0.12 hours	466,667

Form Name	Number of Community Outreach Workers	Number of Respondents Over the Period of the Programs	Number of Responses per Respondent	Total Responses	Average Burden per Response (in hours)	Total Burden Hours
General outreach activities for community members form	Number of community outreach workers deployed for 6 months (HRSA-21-136) or 12 months (HRSA-21-140) of support	Number of community members in contact with community outreach workers	One response per respondent or less (e.g., one response from the audience of a group outreach event)	Reported once across the duration of the programs (the period of performance for HRSA-21-136 is 6 months, and for HRSA-21-140 is 12 months)	Sampled response times of approximately 6 minutes per response	Total hours spent on responses for all funded organizations over a 2-year period
	3,000 (est.)	4,000,000 (est.)	1	4,000,000	0.12 hours	466,667

Form Name	Number of Community Outreach Workers	Number of Respondents Over the Period of the Programs	Number of Responses per Respondent	Total Responses	Average Burden per Response (in hours)	Total Burden Hours
Vaccine-site data – outreach to community members form specifically on booster vaccines	Number of community outreach workers deployed for 6 months (HRSA-21-136) or 12 months (HRSA-21-140) of support	Number of community members in contact with community outreach workers	One response per respondent or less (e.g., one response from the audience of a group outreach event)	Reported once across the duration of the programs (the period of performance for HRSA-21-136 is 6 months, and for HRSA-21-140 is 12 months)	Sampled response times of approximately 6 minutes per response	Total hours spent on responses for all funded organizations over a 2-year period
	3,000 (est.)	4,000,000 (est.)	1	4,000,000	0.12 hours	466,667

Grand Total

12,003,000 (est.)

12,003,000

1,400,801

13. Estimates of Annualized Cost Burden to Respondents

Table 3: Estimated Annualized Cost

Type of Respondent	Total Burden Hours	Hourly Wage Rate	Total Respondent Costs
Community health worker	934,133	$26.25	$24,521,000

Wages of community health workers average $20.19 according to 2020 Occupational Employment Statistics from the U.S. Bureau of Labor Statistics (BLS)². Benefits and fringe are estimated as 30% of the hourly cost or $6.06 per hour. The total hourly cost of clinic managers is therefore estimated as $26.25 per hour composed of $20.19 + $6.06. As mentioned above, it is important to consider that the funding from the CBO programs are creating the job positions for the community outreach workers who will be completing the CBO Program Data Collection Module, and the expended effort to collect this data is considered to be part of the primary role of these job positions.

14. Estimated Cost to the Federal Government

There is no direct cost to the Federal Government for this data collection effort. Monitoring and evaluation of the CBO Programs is an inherent role of current HRSA employees. HRSA has determined the most cost effective approach to data collection and analysis for this program will be to use only Federal staff and open source data collection tools (e.g., Survey Monkey). Thus the estimated cost of using government personnel for these duties will require 15% of 1 FTE at a GS-13 level, Step 2 ($17,453) to provide data analysis and reporting with the total cost to the government of this project for the expected two years of data collection is $34,906).

15. Changes in Burden

This is a new data collection.

16. Time Schedule, Publication and Analysis Plans

The CBO Program Data Reporting Module will be open for data collection on the 1^st of each month (beginning on August 1, 2021). Respondents will have until the 15^th of each month to complete the report. Data from CBO Program will be extracted within two weeks of the end of the reporting period to allow for analysis. CBO Program data collection is limited to two years or the duration of the COVID-19 Public Health Emergency.

17. Exemption for Display of Expiration Date

The expiration date will be displayed.

18. Certifications

This project fully complies with 5 CFR 1320.9.   

1 American Rescue Plan Act, P.L. 117-2.

2 Occupational Employment Statistics. U.S. Bureau of Labor Statistics. Occupational Employment and Wages, May 2020: 21-1094 Community Health Workers. https://www.bls.gov/oes/current/oes211094.htm

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