ASPR Listening Sessions

Form Approved

OMB No. 0990-0379

Exp. Date 08/31/2023

ASPR Listening Session

Stakeholder Registration Form

1. Organization/Company Name:

2. Executive Director/CEO Name: Email: Telephone:

3. Organization/Company Headquarters: City: State:

4. Organization/Company Overview:

• Summarize your organization/company mission, purpose, target audience, and overarching contributions to the preparedness for, response to, and recovery from disasters and other emergencies (Determine word limit)

5. Organization/Company Capabilities:

• List the key capabilities of your organization/company for the preparedness for, response to, and recovery from disasters and other emergencies

Capability 1: (Determine word limit)

Capability 2: (Determine word limit)

Capability 3: (Determine word limit)

6. Organization/Company Disaster Experience:

• Describe any successes, challenges, and issues your organization/company experienced during the COVID-19 pandemic and/or previous disasters that you believe need to be addressed at the federal level for the future (Determine word limit)

7. Listening Session Preference:

   • Please choose your organization/company’s preferred listening session

     1. Public Health Sector

     2. Healthcare Sector

     3. Supply Chain Sector

8. Organization/Company Representatives:

• Participation in the Listening Session is limited to no more than 3 organization/business representatives.

Representative #1:

Name: Email: Telephone:

Representative #2:

Name: Email: Telephone:

Representative #3:

Name: Email: Telephone:

Other:

[Create a text box for additional comments/information]

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer