0990-0459 FT GENERIC tool data collection_CHO

OMB No. 0990-0459

Exp. Date 11/30/2026

QUESTIONS FOR POP-UP SURVEY

These questions would appear in a pop-up survey after someone uses the tool. The text that is in blue is what the calculator user would see.

Screen 1:

Thank you for using the Climate Health Outlook (CHO). Please take 3-4 minutes to give us your feedback to improve this tool!

Please choose one: <Question one creates a branch, sending caseworkers and benefits recipients down separate arms of the survey. Respondents will EITHER complete branch A OR B, not both.>

I am reading this as a private citizen B. I represent a health organization/am a health care provide

↓ ↓

Screen 2/Private Citizen (PC) How easy or difficult was it to use the tool? <slider allows user to move on a continuum between “Very Hard” and “Very Easy”>	Screen 2/Health Organization (HO) and Health Providers How easy or difficult was it to use the tool? <slider allows user to move on a continuum between “Very Hard” and “Very Easy”>
Screen 3/BR How useful are the results that the tool provided? (Did you learn anything that could help you plan your response to climate change/extreme weather events?) <slider allows user to move on a continuum between “Very Useful” and “Not Useful At All”>	Screen 3/CW How useful are the results that the tool provided? (Did you learn anything that could your organization respond to climate change/extreme weather events)? <slider allows user to move on a continuum between “Very Useful” and “Not Useful At All”>
Screen 4: BR What is your next step? <select all that apply> Plan for forecasted climate hazards. Access relevant federal resources. Take personal action to reduce climate change. Take personal action to reduce my risk from extreme weather events. No need for any next steps at this time. I’m not sure.	Screen 4a: CW What is your next step? <select all that apply> Communicate the forecast to my constituents/patients. Improve climate resilience of our facilities. Pre-plan for hazards like heat waves, floods, droughts and wildfire. Raise constituent/patient awareness of connection between weather, climate change, and health. Raise awareness of which patients are at greatest risk from extreme weather events. No need for any next steps at this time. I’m not sure.
	Screen 4b: If HO/HC selected the fifth bullet in 4a, they will see this screen I have a plan to protect my constituents/patients who are at greatest risk for climate change: <Yes/No>
Screen 5: BR How could we make this tool better? <open ended response> there would be a large “DONE” button at the end.	Screen 5: CW How could we make this tool better? <open ended response> there would be a large “DONE” button at the end.
Screen 6: BR Thank you!	Screen 6: CW Thank you!

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 5 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