GenIC Request

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0923-0047)

TITLE OF INFORMATION COLLECTION: Environmental Justice Index Workshop Feedback Surveys

PURPOSE:

CDC/ATSDR will conduct ten informational workshops on the Environmental Justice Index that will be open to public registration. These workshops will be conducted via webinar. During each workshop, attendees will have the option to join up to three sessions. At the end of each session, attendees will be given the option to provide feedback on that session.

The following is a list of sessions and online surveys:

1. Environmental Justice Index Breakout Session

2. Environmental Justice Index Use Case Breakout Session

3. Environmental Justice Index Explorer Demo Session

Feedback provided through these in-workshop surveys will be used to improve functionality of the Environmental Justice Index mapping interface and messaging around the calculation and use of the index.

DESCRIPTION OF RESPONDENTS: Environmental justice advocates, health officials, and subject matter experts on environmental justice and health

TYPE OF COLLECTION: (Check one)

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

[ ] Usability Testing (e.g., Website or Software) [ ] Small Discussion Group

[ ] Focus Group [ x ] Other: EJI Workshop Feedback

Surveys

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.

7. 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	Participation Time	Burden
EJI Breakout Session Attendees	440	3 mins	22 hours
EJI Use Case Breakout Session Attendees	440	3 mins	22 hours
EJI Explorer Demo Session Attendees	440	3 mins	22 hours
Totals			66 hours

FEDERAL COST: The estimated annual cost to the Federal government is $6,400.

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?

Workshops will be open to the public and will be promoted through a number of channels designed to reach a target audience of environmental justice advocates, health officials, and subject matter experts on environmental justice and health. These channels will include:

1. US Department of Health and Human Services Office of Climate and Health Equity email listserv

2. US Environmental Protection Agency Environmental Justice email listserv

3. @CDCEnvironment Twitter Account

4. Agency for Toxic Substances and Disease Registry Place and Health website (https://www.atsdr.cdc.gov/placeandhealth/howdoesPlaceaffectHealth.html)

Preliminary recruitment messages for these online, informational workshops are included as Attachment A of this package.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ x ] Other, Explain Online surveys will be administered during webinar workshop sessions.

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

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

List of Attachments

Attachment A. Environmental Justice Index Informational Workshop Recruiting Messages

Attachment B. Environmental Justice Index Breakout Session Survey (online)

Attachment B. Environmental Justice Index Breakout Session Survey (Word)

Attachment C. Environmental Justice Index Use Case Breakout Session Survey (online)

Attachment C. Environmental Justice Index Use Case Breakout Session Survey (Word)

Attachment D. Environmental Justice Index Explorer Demo Session Survey (online)

Attachment D. Environmental Justice Index Explorer Demo Session Survey (Word)

Attachment E. STARS Determination Form

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.

7