FastTrack GenIC Submission Form - Feedback Questions for Disaster Human Services Seminar

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0970-0401)

TITLE OF INFORMATION COLLECTION: Feedback Questions for Disaster Human Services Seminar

PURPOSE: The Office of Human Services Emergency Preparedness and Response (OHSEPR) is hosting a Disaster Human Services Seminar for each of the ten regions. The seminars are intended to advance equitable disaster operations by equipping human services providers and emergency responders with the principles of disaster equity and disaster human services and providing examples of their application in disaster case management operations.

OHSEPR proposes to gather feedback from seminar attendees to improve future disaster human services training(s).

DESCRIPTION OF RESPONDENTS: State, tribal, territorial, and nongovernmental human services providers.

TYPE OF COLLECTION:

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

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

[ ] Focus 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 primary purpose of the results is not for public dissemination.

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 and affiliation: Bridget Miller, OHSEPR Emergency Management Specialist

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

Personally Identifiable Information:

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

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) 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

Information Collection	Category of Respondent	No. of Respondents	No. of Responses per Respondent	Estimated Time per Response	Burden Hours
Disaster Human Services Seminar Feedback Questions	State, tribal, territorial, and nongovernmental human services providers	500	1	5 minutes	42

FEDERAL COST: The estimated annual cost to the Federal government is $600

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?

Disaster Human Services Seminars will be held in each of the ten regions. We anticipate about 500 non-federal attendees at each seminar and expect about 10% of attendees to complete the survey.

Administration of the Instrument

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

[ X ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

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

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