Memo

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0990-0379)

TITLE OF INFORMATION COLLECTION: Key Informant Impact and Gap Feedback Tool - 2021 California Wildfires Disaster

PURPOSE:

The Health and Human Services (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR) Division of Community Mitigation and Recovery (DCMR) is preparing to launch a Health and Social Services (HSS) recovery mission in California as a result of the 2021 Wildfires in concert with the California Office of Emergency Management (CALOES) and as part of a collaborative FEMA effort that includes other HHS operating divisions. Acquiring the full scope and depth of all impacts and gaps to HSS program delivery in the 7 affected counties, is paramount to advancing recovery solutions. ASPR DCMR aims to use this information to more efficiently deliver county recovery solutions, and customer service to HSS stakeholders. ASPR DCMR would like to obtain feedback from HSS officials in 7 counties on the scope, and depth of all impacts and gaps to HSS programs, services and ultimately citizens. Feedback will be collected through 1 method.

1. Participant completion of a voluntary key informant feedback tool.

Feedback will be used only for internal analysis to understand the depth and scope of the wildfire disaster impacts to the HSS programs, services and ultimately citizens in 7 California counties to advance delivery of efficient recovery solutions.

DESCRIPTION OF RESPONDENTS:

All participants will be county-based HSS program officials working in the 7 California counties impacted by the 2021 Wildfires. Participants or Key Informants are CA county-based employees working in HSS programs.

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: Key Informant Feedback Tool (attached)

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.

Name: Roberto Garza, Robert Dugas

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [X] Yes [ ] No

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [X] 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
County-based California HSS program officials	50	0.033 hours	1.65 hours
Totals	50	0.033 hours	1.65 hours

FEDERAL COST: The estimated annual cost to the Federal government is $20K one-time cost.

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 audience of county-based California HSS officials managing programs is currently known and would be the group competing the tool – less than 50 individuals.

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 – Paper-based Key informant feedback tools will be returned by email and collated.

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

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

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.

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