| This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2035-NEW). Responses to this collection of information are voluntary, and are requested from grantees in the Environmental Justice Collaborative Problem-Solving Program and Environmental Justice Government to Government Programs under the authority of the 2022 Inflation Reduction Act and the Consolidated Appropriations Act 2022 (Public Law 117-103). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 20 hours per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. | ||||||||||
| Introduction | ||||||||||
| 1. Public outreach information collections allow EPA and its grantees to get information from communites and stakeholder groups about their (a) priorities and needs, and (b) feedback on EPA's activities and resources. | ||||||||||
| 2. Public outreach is especially important for environmental justice programs, as input from communities and stakeholders helps grantees ensure that the services and activities they offer are relevant, timely, and useful. | ||||||||||
| 3. Collection of information from individuals and groups outside the federal government is governed by the Paperwork Reduction Act (PRA). The PRA aims to ensure that information collected by federal agencies and their grantees have practical utility, and that there is minimal burden to respondents who are asked to provide this information. | ||||||||||
| 4. Federal agencies must obtain approval from the Office of Management and Budget (OMB) for any targeted public outreach with 10 or more people. (Targeted = using a specific set of questions, e.g. in a survey, focus group, or interview). To obtain this approval, agencies must submit an Information Collection Request (ICR) to OMB. | ||||||||||
| 5. An ICR describes an agency's planned information collection activities, including the purpose, practical utility, estimated burden on respondents (e.g., how long focus group or survey will take), and the questions that will be asked. ICRs must be approved before the corresponding information collections can be undertaken. | ||||||||||
| 6. EPA staff are currently developing an ICR that will authorize all public outreach information collection activities by grantees in the EJCPS and EJG2G Programs. In this ICR, EPA staff need to describe all the information collection activities that each grantee will undertake: (a) General needs assessment surveys and interviews, (b) Focus Groups, (c) Feedback Surveys, and (d) Community-Level Health Impact Assessments. | ||||||||||
| Purpose of this Survey | ||||||||||
| 1. EPA needs to learn about your plans for public outreach activities for the next three years (between October 1st 2024 and September 30th 2027), which is the expected authorization period for this ICR. This Excel spreadsheet includes a series of concrete questions about each information collection activity, so hopefully this will be reasonably painless! | ||||||||||
| 2. Please use your grant application, workplan, and any relevant planning/strategy documents as reference points when answering the questions. If you would like further information or assistance as you are working through the questions, please contact your EPA Project Officer -- they are here to help. | ||||||||||
| 3. This survey has five sections, each corresponding to a different topic: needs assessment, focus groups, feedback surveys, commmunity health assessments, and costs and uses of information. We recommend that you work through one section at a time, recording your answers in the Excel spreadsheet. We ask you to use this spreadsheet so that you can take the time to draft and revise answers in collaboration with your team members and partners. | ||||||||||
| 4. After you have finished working through the entire spreadsheet, please copy and paste your answers into the online questionnnaire (link to be provided by your Project Officer). We ask you to do this so that EPA can efficiently download and organize responses from all 186 grantees into a single spreadsheet. The faster EPA can do this, the faster we can provide assistance to each grantee as they continue to finalize their information collection plans. | ||||||||||
| We will start with General Needs Assessment surveys and interviews. Please go to the next tab/sheet (B. Needs Assessment). |
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| GENERAL NEEDS ASSESSMENT | |
| Purpose: To determine the needs of a community, so that grantees can determine how to direct project activities and funds to the most pressing community needs. Grantees will determine in advance if they will be conducting surveys, interviews, or both. | |
| Engagement in this Activity | Answer from Grantee |
| Do you plan to conduct needs assessments as part of your project? If yes, please answer all the questions listed below. If no, you can skip this tab/sheet. Please proceed to the next tab/sheet (C. Focus Groups). |
Yes / No |
| A. RESPONDENT RECRUITMENT & SELECTION | |
| Question | Answer from Grantee |
| 1. Who will be asked to complete a needs assessment survey or interview? *Example 1: People/groups who attend a project event. *Example 2: People who live in the area that will be affected by the project. *Example 3: People who visit the project website. |
1 |
| 2. How will the request to complete a needs assessment be communicated? List all the strategies you plan to use. *Example 1: If people come to the project office in person, will they be verbally asked to complete a needs assessment survey or interview? *Example 2: If you plan to invite people who live in a particular area or community, how will the request be communicated (e.g., flyers, snail mail postcards, phone calls, neighborhood meeting, etc.)? *Example 3: If you plan to invite people who visit the project website, how will the request be communicated (e.g., text on website)? 3. How will the needs assessmment be completed (e.g., online, paper, verbally, all of the above)? List all the options you plan to use, and note if you plan to use different methods for different scenarios. For example, you might give a paper survey to people who visit the project office in person, and you might have an online survey for people who visit the website. |
2. How the request will be communicated = 3. How the needs assessment will be completed = |
| 4. Will you invite everyone to complete the needs assessment, or will you only invite some people? Note: This question is not asking about which individuals would choose to complete the needs assessment. Rather, it focuses on which individuals are being asked/invited to complete the needs assessment. |
4 |
| 5. If applicable, based on answer to Question 4: If you will only invite some people in the group/population to complete the needs assessment, how will you select them? *Example 1: Select a random sample of people from the relevant group/population. *Example 2: Select people based on a non-random principle/criterion, such as representing different needs/goals; representing different communities; selecting every third person who engages with the project office, etc. |
5 |
| B. NUMBER OF HOURS & RESPONDENTS PER YEAR | |
| Question | Answer from Grantee |
| 6. Approximately how long do you think it will take for people to complete the needs assessment? Provide your best estimate, rounded to 5 minute intervals (e.g., 5 minutes, 10 minutes, etc.). If you would prefer to give a range of times, please estimate the shortest and longest times (e.g., 5 minutes - 15 minutes). 7. How did you come up with the time estimate? There are no wrong answers here! For example, your estimate could be based on: your organization's experience in conducting similar needs assessments; your knowledge of other organizations' experience in conducting similar needs assessments; information you have received from a subject matter expert or from guidance material; staff discussions, etc. |
6. Time estimate = 7. Rationale for time estimate = |
| 8. Approximately how many people do you expect will complete the needs assessments during each of these 3 years: (i) October 2024 - September 2025; (ii) October 2025 - September 2026; (iii) October 2026 to September 2027. Provide your best estimate; we realize that we cannot know the precise numbers. For the purpose of this question, you can assume that everyone who is invited to complete the needs assessment will actually complete it. 9. How did you come up with these estimates? There are no wrong answers here! For example, this could be based on: your organization's past experience; your knowledge of other organizations' experiences; information you have received from a subject matter expert or from guidance material; staff discussions; your workplan or strategic plan; etc. |
8. Approximate numbers of people who will complete the needs assessments each year: (i) September 2024 through October 2025 = (ii) September 2025 through October 2026 = (iii) September 2026 through October 2027 = 9. Rationale for estimate of numbers = |
| C. RESPONDENT COMPENSATION | |
| Question | Answer from Grantee |
| 10. Will people who complete a needs assessment be compensated for their time? Note: It may not be standard practice to provide compensation for this type of information collection activity. So it is fine if you are not offering any. If yes, please complete Question 11-12 below, and then proceed to Section D. If no or not applicable, please only complete Question 13 below, and then proceed to Section D. |
10. Yes / No |
IF COMPENSATION WILL BE OFFERED, PLEASE COMPLETE THESE QUESTIONS. 11. What type of compensation will you provide to people and what will be the maximum cash value? Please note that incentives must be reasonable in amount and specifically justified (see next question). If you are not sure how to answer this question, please consult with your EPA Project Officer. For example: $10 cash, $20 gift card, reimbursement of travel expenses up to $20; entry into a raffle/drawing for one of three $100 cash prizes, etc. Be as specific as possible when describing your plans. 12. How did you decide on this compensation type and amount? There are no wrong answers here! For example, this could be based on: your organization's past experience; your knowledge of other organizations' experiences; information you have received from a subject matter expert or from guidance material; staff discussions; your budget; etc. |
IF COMPENSATION WILL BE OFFERED: 11. Compensation type and maximum value = 12. Rationale for compensation type and maximum value = |
IF COMPENSATION WILL BE NOT OFFERED, PLEASE COMPLETE THIS QUESTION. 13. If compensation is not being offered, what strategies will you use to encourage people to complete the needs assessments? * Example: Discuss the benefits of completing the assessment, to the respondent personally and/or to the project more generally. |
IF COMPENSATION WILL NOT BE OFFERED: 13. Strategies to encourage completion of needs asssments = |
| D. ASSURANCE OF PRIVACY | |
| Question | Answer from Grantee |
| 14. If you are conducting interviews, will the sessions be recorded? If yes, please complete Question 15-19 below and then proceed to Section E. If no or not applicable, please only complete Questions 17-19 and then proceed to Section E. |
14. Yes / No / Not applicable - not conducting interviews |
IF INTERVIEWS WILL BE RECORDED: 15. When and how will you obtain consent from participants for the recording? *Examples of when: before the interview (e.g., when they sign up for a session), at the start of the interview, etc. *Example of how: Ask verbally if the participant objects to being recorded 16. What action will you take if a participant objects to being recorded? *Example 1: Thank the participant for their time and tell them that the interview will not be conducted. *Example 2: Proceed with the interview and do not record the session. |
IF INTERVIEWS WILL BE RECORDED: 15. When and how consent will be obtained = 16. Action to be taken if a participant objects to being recorded = |
FOR ALL SURVEYS AND INTERVIEWS (RECORDED OR NOT) 17. Do you expect to collect personally identifiable information during the needs assessment? Per OMB Circular A-130, Personally Identifiable Information (PII) is “information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other information that is linked or linkable to a specific individual (Page 33).” If yes, please list what you will collect. 18. During the needs assessment, do you expect to ask sensitive questions about issues that are normally considered private (e.g., religious beliefs, sexual attitudes and behaviors)? If yes, please list what you will collect. 19. What strategies will you use to assure privacy when storing the surveys or interview notes/ recordings? For example: Will staff receive training in handling personally idenifiable information, will the information be stored in locked cabinets or password-protected computers that can only be accessed by authorized personnel, etc. 20. What strategies will you use to assure privacy when reviewing the surveys or interview notes/recordings? For example: Will staff receive training in handling personally identifiable information, will the notes and/or recordings be discussed only by authorized personnel in secure locations where they cannot be overheard, etc. |
FOR ALL SURVEYS AND INTERVIEWS: 17. Collection of personally identifiable information = Yes / No If Yes, list of what will be collected = 18. Inclusion of sensitive questions = Yes / No If Yes, list of what will be collected = 19. Strategies to assure privacy when storing surveys or interview notes/recordings = 20. Strategies to assure privacy when reviewing surveys or interview notes/recordings = |
| E. DRAFT INSTRUMENT | |
| Question | Answer from Grantee |
| Instructions: Please prepare a full draft of your needs assessment survey and/or interview schedule for EPA to review. This should include all questions/items, response options (e.g., multiple choice with response labels or open-ended), and instructions to respondents. EPA will review the instrument to confirm that its content and structure fits within the parameters of the planned ICR package. 21. When will you provide a draft for EPA to review? |
21. Date that draft instrument will be sent to EPA: |
| We have finished with needs assessments, and will now move on to the second topic: focus groups. Please go to the next tab/sheet (C. Focus groups). |
|
| FOCUS GROUPS | |
| Purposes: (1) Identify the needs, priorities, and goals of people/groups receiving technical services and/or training from the grantee, and/or (2) Help grantees identify pathways for how to best address those needs. | |
| Engagement in this Activity | Answer from Grantee |
| Do you plan to conduct focus groups as part of your project? If yes, please answer all the questions listed below. If no, you can skip this tab/sheet. Please proceed to the next tab/sheet (D. Feedback Surveys). |
Yes / No |
| A. RESPONDENT RECRUITMENT & SELECTION | |
| Question | Answer from Grantee |
| 1. Who will be asked to participate in a focus group? List all the people/groups you plan to invite. *Example 1: People/groups who attend a project event. *Example 2: People who live in the area that will be affected by the project. *Example 3: People who visit the project website. |
1 |
| 2. How will the request to participate in a focus group be communicated? List all the strategies that will be used. *Example 1: If people come to the project office in person, will they be verbally asked to participate in a focus group? *Example 2: If you plan to invite people who live in a particular area or community, how will the request be communicated (e.g., flyers, snail mail postcards, phone calls, neighborhood meeting, etc.)? *Example 3: If you plan to invite people who visit the project website, how will the request be communicated (e.g., text on website)? 3. How will the focus group be conducted? List all the options you could use. * Examples: video call, audio call, in person, any of the above, depending on the group's needs/preferences, etc. |
2. How the request will be communicated = 3. How the focus group will be conducted = |
| 4. Will you invite everyone from the respondent group/population to participate in the focus group, or will you only invite some people? Note: This question is not asking about which individuals would choose to participate in the focus group. Rather, it focuses on which individuals are being asked/invited to participate in the focus group. |
4 |
| 5. If applicable, based on answer to Question 4: If you will only invite some people in the group/population to participate in the focus group, how will you select them? *Example 1: Select a random sample of people from the relevant group/population. *Example 2: Select people based on a non-random principle/criterion, such as different needs/goals; representing different communities, etc. |
5 |
| B. NUMBER OF HOURS & RESPONDENTS PER YEAR | |
| Question | Answer from Grantee |
| 6. How long do you think the focus groups will take? Provide your best estimate, rounded to 15 minute intervals (e.g., 1.5 hours, 2 hours). If you would prefer to give a range of times, please estimate the shortest and longest times (e.g., 1 - 2 hours). 7. How did you come up with the time estimate? There are no wrong answers here! For example, your estimate could be based on: your organization's experience in conducting focus groups; your knowledge of other organizations' experience in conducting focus groups; information you have received from a subject matter expert or from guidance material; staff discussions, etc. |
6. Time estimate = 7. Rationale for time estimate = |
| 8. Approximately how many people will participate in each focus group? Provide your best estimate; we realize that we cannot know the precise numbers. For the purpose of this question, you can assume that everyone who is invited to participate in a focus group will actually participate. 9. Approximately how many focus groups do you expect to conduct during each of these 3 years: (i) October 2024 - September 2025; (ii) October 2025 - September 2026; (iii) October 2026 to September 2027. Provide your best estimate; we realize that we cannot know the precise numbers. For the purpose of this question, you can assume that everyone who is invited to join a focus group will actually participate. 10. How did you come up with these estimates? There are no wrong answers here! For example, this could be based on: your organization's past experience; your knowledge of other organizations' experiences; information you have received from a subject matter expert or from guidance material; staff discussions; your workplan or strategic plan; etc. |
8. Approximate numbers of people in each focus group = 9. Approximate number of focus groups you plan to conduct each year: (i) September 2024 through October 2025 = (ii) September 2025 through October 2026 = (iii) September 2026 through October 2027 = 10. Rationale for estimates of numbers = |
| C. RESPONDENT COMPENSATION | |
| Question | Answer from Grantee |
| 11. Will people who participate in a focus group be compensated for their time? | 11. Yes / No |
IF COMPENSATION WILL BE OFFERED, PLEASE COMPLETE THIS QUESTION. 12. What type of compensation will you provide to people and what will be the maximum cash value? Please note that incentives must be reasonable in amount and specifically justified (see next question). If you are not sure how to answer this question, please consult with your EPA Project Officer. For example: $10 cash, $20 gift card, reimbursement of travel expenses up to $20; entry into a raffle/drawing for one of three $100 cash prizes, etc. Be as specific as possible when describing your plans. 13. How did you decide on this compensation type and amount? There are no wrong answers here! For example, this could be based on: your organization's past experience; your knowledge of other organizations' experiences; information you have received from a subject matter expert or from guidance material; staff discussions; your budget; etc. |
IF APPLICABLE: 12. Compensation type and maximum value = 13. Rationale for compensation type and maximum value = |
IF COMPENSATION WILL BE NOT OFFERED, PLEASE COMPLETE THIS QUESTION. 14. If compensation is not being offered, what strategies will you use to encourage people to participate in a focus group? For example: Discuss the benefits of participating in a focus group, to the respondent personally and/or to the project generally. |
IF APPLICABLE: 14. Strategies to encourage participation in focus groups = |
| D. SENSITIVE QUESTIONS AND ASSURANCE OF PRIVACY | |
| Question | Answer from Grantee |
| 15. Will the focus group sessions be recorded? If yes, please complete Question 16-20 below and then proceed to Section E. If no, please only complete Questions 18-20 and then proceed to Section E. |
15. Yes / No |
IF FOCUS GROUP SESSIONS WILL BE RECORDED: 16. When and how will you obtain consent from participants for the recording? *Examples of when: Before the focus group (e.g., when respondents sign up for a session), at the start of the focus group session, etc. *Example of how: Ask verbally if anyone objects to being recorded 17. What action will you take if a participant objects to being recorded? *Example 1: Thank the participant for their time and invite them to leave the session. After the participant has left, record the session with all participants who have provided consent. *Example 2: Allow all participants to complete the focus group, and do not record the session. |
IF FOCUS GROUP SESSIONS WILL BE RECORDED: 16. When and how consent will be obtained = 17. Action taken if a participant objects to being recorded = |
FOR ALL FOCUS GROUP SESSIONS (RECORDED OR NOT) 18. Do you expect to collect personally identifiable information during the focus group? Per OMB Circular A-130, Personally Identifiable Information (PII) is “information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other information that is linked or linkable to a specific individual (Page 33).” If yes, please list what you will collect. 19. During the focus group, do you expect to ask sensitive questions about issues that are normally considered private (e.g., religious beliefs, sexual attitudes and behaviors)? If yes, please list what you will collect. 20. What strategies will you use to assure privacy when storing the notes and/or recordings from each focus group session? For example: Will staff receive training in handling personally identifiable information, will the information be stored in locked cabinets or password-protected computers that can only be accessed by authorized personnel, etc. 21. What strategies will you use to assure privacy when reviewing the notes and/or recordings from each focus group session? For example: Will staff receive training in handling personally identifiable information, will the notes and/or recordings be discussed only by authorized personnel in secure locations where they cannot be overheard, etc. |
FOR ALL FOCUS GROUP SESSIONS: 18. Collection of personally identifiable information = Yes / No If Yes, list of what will be collected = 19. Inclusion of sensitive questions = Yes / No If Yes, list of what will be collected = 20. Strategies to assure privacy when storing notes and/or recordings from each focus group session = 21. Strategies to assure privacy when reviewing notes and/or recordings from each focus group session = |
| E. DRAFT INSTRUMENT | |
| Question | Answer from Grantee |
| Instructions: Please develop a full draft of your focus group questions for EPA to review. This should include all discussion topics and instructions to respondents. EPA will review the instrument to confirm that its content and structure fits within the parameters of the planned ICR package. 22. When will you provide a draft for EPA to review? |
22. Date that draft instrument will be sent to EPA: |
| We have finished with focus groups, and will now move on to the third topic, feedback surveys. Please go to the next sheet/tab (D. Feedback Surveys). |
|
| FEEDBACK SURVEYS | |
| Purpose: Get feedback on project services, either about a specific activity (e.g., workshop) or about project activities more broadly | |
| Engagement in this Activity | Answer from Grantee |
| Do you plan to conduct feedback surveys as part of your project? If yes, please answer all the questions listed below. If no, you can skip this tab/sheet. Please proceed to the next tab/sheet (E. Community Health Assessments). |
Yes / No |
| A. RESPONDENT RECRUITMENT & SELECTION | |
| Question | Answer from Grantee |
| 1. How and when do you plan to use feedback surveys? List all your plans. *Example 1: To get specific feedback after a particular project activity (e.g., training session). *Example 2: To get general feedback on project activities, collected every year (or a different time interval). |
1 |
| 2. Who will be asked to complete each type of feedback survey you plan to use? List all the people/groups you plan to invite. *Example 1: General feedback survey - People/groups who have engaged with the project at least once *Example 2: Specific feedback survey - People/groups who have participated in the relevant project activity |
2 |
| 3. How will the requests to complete a feedback survey be communicated? List all the strategies that will be used. *Example 1: General feedback survey - Emails/phone calls to all people/groups on the project contact list *Example 2: Specific feedback survey - announcement at the end of the event/activity/gathering that will be assessed. 4. How will the feedback survey be completed (e.g., online, paper, verbally, all of the above)? List all the options you plan to use. |
3. How the requests will be communicated = 4. How the feedback survey will be completed = |
| 5. Will you invite everyone from the relevant respondent group/population to complete the feedback survey (e.g., all participants in an activity or all people on the project contact list), or will you only invite some people? Note: This question is not asking about which individuals would choose to complete the feedback survey. Rather, it focuses on which individuals are being asked/invited to complete the feedback survey. |
5 |
| 6. If applicable, based on answer to Question 5: If you will only invite some people in the group/population to complete the feedback survey, how will you select them? *Example 1: Select a random sample of people from the relevant group/population. *Example 2: Select people based on a non-random principle/criterion, such as different needs/goals; representing different communities, etc. |
6 |
| B. NUMBER OF HOURS & RESPONDENTS PER YEAR | |
| Question | Answer from Grantee |
| 7. Approximately how long do you think it will take for people to complete each type of feedback survey that you plan to use (e.g., general feedback on all activities, specific feedback on an activity/event/service)? Provide your best estimate, rounded to 5 minute intervals (e.g., 5 minutes, 20 minutes, 45 minutes). If you would prefer to give a range of times, please estimate the shortest and longest times (e.g., 15 minutes - 45 minutes). 8. How did you come up with the time estimates? There are no wrong answers here! For example, your estimate could be based on: your organization's experience in conducting similar surveys; your knowledge of other organizations' experience in conducting similar surveys; information you have received from a subject matter expert or from guidance material; staff discussions, etc. |
7. Time estimate = 8. Rationale for time estimates = |
| ANSWER THESE QUESTIONS IF APPLICABLE: 9. If you are going to use general feedback surveys, approximately how many people do you expect will complete these surveys during each of these 3 years: (i) October 2024 - September 2025; (ii) October 2025 - September 2026; (iii) October 2026 to September 2027. Provide your best estimate; we realize that we cannot know the precise numbers. For the purpose of this question, you can assume that everyone who is invited to complete the general feedback survey will actually complete it. 10. How did you come up with these estimates? There are no wrong answers here! For example, this could be based on: your organization's past experience; your knowledge of other organizations' experiences; information you have received from a subject matter expert or from guidance material; staff discussions; your workplan or strategic plan; etc. |
IF APPLICABLE: 9. Approximate number of people who will complete the general feedback surveys in each year: (i) September 2024 through October 2025 = (ii) September 2025 through October 2026 = (iii) September 2026 through October 2027 = 10. Rationale for estimates of numbers = |
| ANSWER THESE QUESTIONS IF APPLICABLE: 11. If you are going to use specific feedback surveys, approximately how many activities do you plan to use them in, for each of these 3 years: (i) October 2024 - September 2025; (ii) October 2025 - September 2026; (iii) October 2026 to September 2027. Provide your best estimate; we realize that we cannot know the precise numbers. For the purpose of this question, you can assume that everyone who is invited to complete a feedback survey will actually complete it. (If none, write 0). 12. If you are going to use specific feedback surveys, approximately how many people do you expect will complete the particular services/activities/events during each of the 3 years: (i) October 2024 - September 2025; (ii) October 2025 - September 2026; (iii) October 2026 to September 2027. Provide your best estimate; we realize that we cannot know the precise numbers. For the purpose of this question, you can assume that everyone who is invited to complete the specific feedback survey will actually complete it. Don't worry about "double-counting" people: if a person participates in multiple workshops, they count as a separate respondent for each specific feedback survey that they complete. 13. How did you come up with these estimates? There are no wrong answers here! For example, this could be based on: your organization's past experience; your knowledge of other organizations' experiences; information you have received from a subject matter expert or from guidance material; staff discussions; your workplan or strategic plan; etc. |
IF APPLICABLE: 11. Approximate number of specific activities you plan to use specific feedback surveys in, for each year: (i) September 2024 through October 2025 = (ii) September 2025 through October 2026 = (iii) September 2026 through October 2027 = 12. Approximate number of people who will complete specific feedback surveys, during each year: (i) September 2024 through October 2025 = (ii) September 2025 through October 2026 = (iii) September 2026 through October 2027 = 13. Rationale for estimates of numbers = |
| C. RESPONDENT COMPENSATION | |
| Question | Answer from Grantee |
| 14. Will people who complete a feedback survey be compensated for their time? Provide an answer for each type of feedback survey you plan to use (i.e., general feedback on all project activities, specific feedback on a particular service/activity). | 14. Yes / No |
IF COMPENSATION WILL BE OFFERED, PLEASE COMPLETE THIS QUESTION. 15. What type of compensation will you provide to people and what will be the maximum cash value? Please note that incentives must be reasonable in amount and specifically justified (see next question). If you are not sure how to answer this question, please consult with your EPA Project Officer. For example: $10 cash, $20 gift card, reimbursement of travel expenses up to $20; entry into a raffle/drawing for one of three $100 cash prizes, etc. Provide an answer for each type of feedback survey you plan to use (i.e., general feedback on all project activities, specific feedback on a particular activity). 16. How did you decide on this compensation type and amount? There are no wrong answers here! For example, this could be based on: your organization's past experience; your knowledge of other organizations' experiences; information you have received from a subject matter expert or from guidance material; staff discussions; your budget; etc. |
IF APPLICABLE: 15. Compensation type and maximum value = 16. Rationale for compensation type and maximum value = |
IF COMPENSATION WILL BE NOT OFFERED, PLEASE COMPLETE THIS QUESTION. 17. If compensation is not being offered, what strategies will you use to encourage people to complete a feedback survey? Provide an answer for each type of feedback survey you plan to use (i.e., general feedback on all project activities, specific feedback on a particular project activity). For example: Discuss the benefits of completing a feedback survey, to the respondent personally and/or to the project more generally. |
IF APPLICABLE: 17. Strategies to encourage completion of feedback surveys = |
| D. ASSURANCE OF PRIVACY | |
| Question | Answer from Grantee |
| 18. Do you expect to collect personally identifiable information as part of the general feedback survey or specific feedback surveys? Per OMB Circular A-130, Personally Identifiable Information (PII) is “information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other information that is linked or linkable to a specific individual (Page 33).” If yes, please list what you will collect. 19. In the general feedback survey or the specific feedback survey, do you expect to ask sensitive questions about issues that are normally considered private (e.g., religious beliefs, sexual attitudes and behaviors)? If yes, please list what you will collect. 20. What strategies will you use to assure privacy when storing the survey responses? For example: Will staff receive training in handling personally identifiable information, will the survey responses be stored in locked cabinets or password-protected computers that can only be accessed by authorized personnel, etc. 21. What strategies will you use to assure privacy when reviewing the surveys? For example: Will staff receive training in handling personally identifiable information, will the surveys be discussed only by authorized personnel in secure locations where they cannot be overheard, etc. |
18. Collection of personally identifiable information = Yes / No If Yes, list of what will be collected = 19. Inclusion of senstitive questions = Yes / No If Yes, list of what will be collected = 20. Strategies to assure privacy when storing surveys = 21. Strategies to assure privacy when reviewing notes from each survey = |
| E. DRAFT INSTRUMENT | |
| Question | Answer from Grantee |
| Instructions: Please develop a full draft of each feedback survey for EPA to review. This should include all questions/items, response options (e.g., multiple choice with response labels or open-ended), and instructions to respondents. EPA will review the instruments to confirm that their content and structure fit within the parameters of the planned ICR package. 22. When will you provide drafts for EPA to review? |
22. Date that draft instrument(s) will be sent to EPA: |
| We have finished with feedback surveys, and will now move on to the fourth topic, community level health assessments. Please go to the next sheet/tab (E. Community Health Assessments). |
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| COMMUNITY HEALTH IMPACT ASSESSMENTS | |
| Description: Some EJCPS and EJG2G grantees will conduct community-level Health Impact Assessments, which aim to protect and promote health and to reduce inequities in health during a decision-making process. The assessments will contain six components: screening, scoping, assessment, recommendations, reporting, and monitoring and evaluation. | |
| Engagement in this Activity | Answer from Grantee |
| Do you plan to conduct a community-level Health Impact Assessment as part of your project? If yes, please answer all the questions listed below. If no, you can skip this tab/sheet. Please proceed to the next tab/sheet (F. Costs + Uses of Information). |
Yes / No |
| A. COMPONENT 1: SCREENING | |
| Question | Answer from Grantee |
| 1. What information will you collect from the public (individuals or organizations outside the federal government) for the screening component of the community health impact assessment? If you will not collect any information from the public for this component of the assessment, please leave the rest of this section blank and proceed to Section B (Row 15). |
1. Information = OR Not applicable |
| 2. Do you expect to collect personally identifiable information for this component of the assessment? Per OMB Circular A-130, Personally Identifiable Information (PII) is “information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other information that is linked or linkable to a specific individual (Page 33).” If yes, please list what you will collect. 3. Do you expect to ask sensitive questions about issues that are normally considered private (e.g., religious beliefs, sexual attitudes and behaviors) for this component of the assessment? If yes, please list what you will collect. |
2. Collection of personally identifiable information = Yes / No If Yes, list of what will be collected = 3. Inclusion of sensitive questions = Yes / No If Yes, list of what will be collected = |
| 4. From what source(s) will you collect each piece of information for this component of the assessment? 5. If the source(s) are individuals or organizations, please estimate the amount of time it will take them to provide the requested information. |
4. Sources = 5. Amount of time = |
| 6. How will the requests for information be communicated? 7. How will the information be collected (e.g., online, paper, verbally, all of the above)? |
6. How the requests will be communicated = 7. How the information will be collected = |
| 8. What strategies will you use to assure privacy when storing the collected information? For example: Will staff receive training in handling personally identifiable information, will the information be stored in locked cabinets or password-protected computers that can only be accessed by authorized personnel, etc. 9. What strategies will you use to assure privacy when reviewing the collected information? For example: Will staff receive training in handling personally identifiable information, will the information be discussed only by authorized personnel in secure locations where they cannot be overheard, etc. |
8. Strategies to assure privacy when storing information = 9. Strategies to assure privacy when reviewing information = |
| B. COMPONENT 2: SCOPING | |
| Question | Answer from Grantee |
| 10. What information will you collect from the public (individuals or organizations outside the federal government) for the scoping component of the community health impact assessment? If you will not collect any information from the public for this component of the assessment, please leave the rest of this section blank and proceed to Section C (Row 23). |
10. Information = OR Not applicable |
| 11. Do you expect to collect personally identifiable information for this component of the assessment? Per OMB Circular A-130, Personally Identifiable Information (PII) is “information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other information that is linked or linkable to a specific individual (Page 33).” If yes, please list what you will collect. 12. Do you expect to ask sensitive questions about issues that are normally considered private (e.g., religious beliefs, sexual attitudes and behaviors) for this component of the assessment? If yes, please list what you will collect. |
11. Collection of personally identifiable information = Yes / No If Yes, list of what will be collected = 12. Inclusion of sensitive questions = Yes / No If Yes, list of what will be collected = |
| 13. From what source(s) will you collect each piece of information for this component of the assessment? 14. If the source(s) are individuals or organizations, please estimate the amount of time it will take them to provide the requested information. |
13. Sources = 14. Amount of time = |
| 15. How will the requests for information be communicated? 16. How will the information be collected (e.g., online, paper, verbally, all of the above)? |
15. How the requests will be communicated = 16. How the information will be collected = |
| 17. What strategies will you use to assure privacy when storing the collected information? For example: Will staff receive training in handling personally identifiable information, will the information be stored in locked cabinets or password-protected computers that can only be accessed by authorized personnel, etc. 18. What strategies will you use to assure privacy when reviewing the collected information? For example: Will staff receive training in handling personally identifiable information, will the information be discussed only by authorized personnel in secure locations where they cannot be overheard, etc. |
17. Strategies to assure privacy when storing information = 18. Strategies to assure privacy when reviewing information = |
| C. COMPONENT 3: ASSESSMENT | |
| Question | Answer from Grantee |
| 19. What information will you collect from the public (individuals or organizations outside the federal government) for the assessment component of the community health impact assessment? If you will not collect any information from the public for this component of the assessment, please leave the rest of this section blank and proceed to Section D (Row 31). |
19. Information = OR Not applicable |
| 20. Do you expect to collect personally identifiable information for this component of the assessment? Per OMB Circular A-130, Personally Identifiable Information (PII) is “information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other information that is linked or linkable to a specific individual (Page 33).” If yes, please list what you will collect. 21. Do you expect to ask sensitive questions about issues that are normally considered private (e.g., religious beliefs, sexual attitudes and behaviors) for this component of the assessment? If yes, please list what you will collect. |
20. Collection of personally identifiable information = Yes / No If Yes, list of what will be collected = 21. Inclusion of sensitive questions = Yes / No If Yes, list of what will be collected = |
| 22. From what source(s) will you collect each piece of information for this component of the assessment? 23. If the source(s) are individuals or organizations, please estimate the amount of time it will take them to provide the requested information. |
22. Sources = 23. Amount of time = |
| 24. How will the requests for information be communicated? 25. How will the information be collected (e.g., online, paper, verbally, all of the above)? |
24. How the requests will be communicated = 25. How the information will be collected = |
| 26. What strategies will you use to assure privacy when storing the collected information? For example: Will staff receive training in handling personally identifiable information, will the information be stored in locked cabinets or password-protected computers that can only be accessed by authorized personnel, etc. 27. What strategies will you use to assure privacy when reviewing the collected information? For example: Will staff receive training in handling personally identifiable information, will the information be discussed only by authorized personnel in secure locations where they cannot be overheard, etc. |
26. Strategies to assure privacy when storing information = 27. Strategies to assure privacy when reviewing information = |
| D. COMPONENT 4: RECOMMENDATIONS | |
| Question | Answer from Grantee |
| 28. What information will you collect from the public (individuals or organizations outside the federal government) for the recommendations component of the community health impact assessment? If you will not collect any information from the public for this component of the assessment, please leave the rest of this section blank and proceed to Section E (Row 39). |
28. Information = OR Not applicable |
| 29. Do you expect to collect personally identifiable information for this component of the assessment? Per OMB Circular A-130, Personally Identifiable Information (PII) is “information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other information that is linked or linkable to a specific individual (Page 33).” If yes, please list what you will collect. 30. Do you expect to ask sensitive questions about issues that are normally considered private (e.g., religious beliefs, sexual attitudes and behaviors) for this component of the assessment? If yes, please list what you will collect. |
29. Collection of personally identifiable information = Yes / No If Yes, list of what will be collected = 30. Inclusion of sensitive questions = Yes / No If Yes, list of what will be collected = |
| 31. From what source(s) will you collect each piece of information for this component of the assessment? 32. If the source(s) are individuals or organizations, please estimate the amount of time it will take them to provide the requested information. |
31. Sources = 32. Amount of time = |
| 33. How will the requests for information be communicated? 34. How will the information be collected (e.g., online, paper, verbally, all of the above)? |
33. How the requests will be communicated = 34. How the information will be collected = |
| 35. What strategies will you use to assure privacy when storing the collected information? For example: Will staff receive training in handling personally identifiable information, will the information be stored in locked cabinets or password-protected computers that can only be accessed by authorized personnel, etc. 36. What strategies will you use to assure personally identifiable information when reviewing the collected information? For example: Will staff receive training in handling personally identifiable information, will the information be discussed only by authorized personnel in secure locations where they cannot be overheard, etc. |
35. Strategies to assure privacy when storing information = 36. Strategies to assure privacy when reviewing information = |
| E. COMPONENT 5: REPORTING | |
| Question | Answer from Grantee |
| 37. What information will you collect from the public (individuals or organizations outside the federal government) for the reporting component of the community health impact assessment? If you will not collect any information from the public for this component of the assessment, please leave the rest of this section blank and proceed to Section F (Row 47). |
37. Information = OR Not applicable |
| 38. Do you expect to collect personally identifiable information for this component of the assessment? Per OMB Circular A-130, Personally Identifiable Information (PII) is “information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other information that is linked or linkable to a specific individual (Page 33).” If yes, please list what you will collect. 39. Do you expect to ask sensitive questions about issues that are normally considered private (e.g., religious beliefs, sexual attitudes and behaviors) for this component of the assessment? If yes, please list what you will collect. |
38. Collection of personallly identifiable information = Yes / No If Yes, list of what will be collected = 39. Inclusion of sensitive questions = Yes / No If Yes, list of what will be collected = |
| 40. From what source(s) will you collect each piece of information for this component of the assessment? 41. If the source(s) are individuals or organizations, please estimate the amount of time it will take them to provide the requested information. |
40. Sources = 41. Amount of time = |
| 42. How will the requests for information be communicated? 43. How will the information be collected (e.g., online, paper, verbally, all of the above)? |
42. How the requests will be communicated = 43. How the information will be collected = |
| 44. What strategies will you use to assure privacy when storing the collected information? For example: Will staff receive training in handling personally identifiable information, will the information be stored in locked cabinets or password-protected computers that can only be accessed by authorized personnel, etc. 45. What strategies will you use to assure privacy when reviewing the collected information? For example: Will staff receive training in handling personally identifiable information, will the information be discussed only by authorized personnel in secure locations where they cannot be overheard, etc. |
44. Strategies to assure privacy when storing information = 45. Strategies to assure privacy when reviewing information = |
| F. COMPONENT 6: MONITORING AND EVALUATION | |
| Question | Answer from Grantee |
| 46. What information will you collect from the public (individuals or organizations outside the federal government) for the monitoring and evaluation component of the community health impact assessment? If you will not collect any information from the public for this component of the assessment, please leave the rest of this section blank and proceed to the last section of this sheet (Row 56). |
46. Information = OR Not applicable |
| 47. Do you expect to collect personally identifiable information for this component of the assessment? Per OMB Circular A-130, Personally Identifiable Information (PII) is “information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other information that is linked or linkable to a specific individual (Page 33).” If yes, please list what you will collect. 48. Do you expect to ask sensitive questions about issues that are normally considered private (e.g., religious beliefs, sexual attitudes and behaviors) for this component of the assessment? If yes, please list what you will collect. |
47. Collection of personally identifiable information = Yes / No If Yes, list of what will be collected = 48. Inclusion of sensitive questions = Yes / No If Yes, list of what will be collected = |
| 49. From what source(s) will you collect each piece of information for this component of the assessment? 50. If the source(s) are individuals or organizations, please estimate the amount of time it will take them to provide the requested information. |
49. Sources = 50. Amount of time = |
| 51. How will the requests for information be communicated? 52. How will the information be collected (e.g., online, paper, verbally, all of the above)? |
51. How the requests will be communicated = 52. How the information will be collected = |
| 53. What strategies will you use to assure privacy when storing the collected information? For example: Will staff receive training in handling personally identifiable information, will the information be stored in locked cabinets or password-protected computers that can only be accessed by authorized personnel, etc. 54. What strategies will you use to assure privacy when reviewing the collected information? For example: Will staff receive training in handling personally identifiable information, will the information be discussed only by authorized personnel in secure locations where they cannot be overheard, etc. |
53. Strategies to assure privacy when storing information = 54. Strategies to assure privacy when reviewing information = |
| G. RESPONDENT COMPENSATION | |
| Question | Answer from Grantee |
| 55. Will any individuals or groups who provide information for a community health assessment be compensated for their time? Provide an answer for each type of feedback survey you plan to use (i.e., general feedback on all project activities, specific feedback on a particular service/activity). If yes, please list the activities in each component for which you will be providing compensation. For example, Screening Component Survey of Health Centers. |
55. Yes / No If yes, activities in each component: |
IF COMPENSATION WILL BE OFFERED, PLEASE COMPLETE THIS QUESTION. 56. What type of compensation will you provide for each of the activities/components listed in Q55 and what will be the maximum cash value? Please note that incentives must be reasonable in amount and specifically justified (see next question). If you are not sure how to answer this question, please consult with your EPA Project Officer. For example: $10 cash, $20 gift card, reimbursement of travel expenses up to $20; entry into a raffle/drawing for one of three $100 cash prizes, etc. Provide an answer for each type of feedback survey you plan to use (i.e., general feedback on all project activities, specific feedback on a particular activity). 57. How did you decide on the compensation type(s) and amount(s) for each of the activities/components listed in Q55? There are no wrong answers here! For example, this could be based on: your organization's past experience; your knowledge of other organizations' experiences; information you have received from a subject matter expert or from guidance material; staff discussions; your budget; etc. |
IF APPLICABLE: 56. Compensation type and maximum value (for each activity listed in Q55) = 57. Rationale for compensation type and maximum value (for each activity listed in Q55) = |
IF COMPENSATION WILL BE NOT OFFERED, PLEASE COMPLETE THIS QUESTION. 58. If compensation is not being offered, what strategies will you use to encourage people to complete a feedback survey? Provide an answer for each type of feedback survey you plan to use (i.e., general feedback on all project activities, specific feedback on a particular project activity). For example: Discuss the benefits of completing a feedback survey, to the respondent personally and/or to the project more generally. |
IF APPLICABLE: 58. Strategies to encourage completion of feedback surveys = |
| G. DRAFT INSTRUMENT | |
| Question | Answer from Grantee |
| Instructions: Please develop a full draft of each Community Health Assessment instrument (e.g., survey, interview, etc.) for EPA to review. This should include all questions/items, response options (e.g., multiple choice with response labels or open-ended), and instructions to respondents. EPA will review the instruments to confirm that their content and structure fit within the parameters of the planned ICR package. 59. When will you provide drafts for EPA to review? |
59. Date that draft instrument(s) will be sent to EPA: |
| This is the last information collection activity! We now have a few final questions about the costs to your organization for collecting this inforation and your plans for using the collected information. Please go to the last sheet/tab (F. Costs + Uses of Information). | |
| COSTS & USES OF INFORMATION | |
| Description: In this final section, we have some general questions for you about the costs associated with collecting this information and your plans for using the collected information. When answering these questions, think about your plans across all of the information collection activities you plan to use (i.e., some or all of the following: needs assessment, focus groups, feedback surveys, community health assessments). | |
| A. COSTS OF COLLECTING INFORMATION | |
| Question | Answer from Grantee |
| 1. Do you expect to incur any specific capital or start-up costs for your planned needs assessment surveys/interviews, focus groups, feedback surveys, or community health assessments? That is, do you need to purchase any equipment (e.g., computer, software packages) or infrastructure (e.g., work space, access to internet services) solely for the information collection activities, that you would not otherwise be using? It's fine if you do not have any unique capital or start-up costs associated with these planned information collection activities. If yes, please list the specific capital and/or start-up items and costs. |
1. Yes / No If yes: please list the specific capital and/or start-up cost items and costs. |
| 2. Do you expect to incur any specific operation or maintenance costs for your planned needs assessment surveys or interviews, focus groups, feedback surveys, or community health assessments? That is, do you need to spend funds on operating or maintaining any equipment or infrastructure that has been purchased solely for these planned information collection activities? Please also consider if you plan to purchase any services to conduct your planned information collection activities. It's fine if you do not have any unique operation or maintenance costs associated with these planned information collection activities. If yes, please list the specific costs associated with operation, maintenance, and/or purchase of services. |
2. Yes / No If yes: please list the specific costs associated with operation, maintenance, and/or purchase of services. |
| B. USES OF COLLECTED INFORMATION | |
| Question | Answer from Grantee |
| 3. Do you plan to use the collected information to help inform project decisions? This could include using needs assessments and focus groups to identifying strategies to address community needs and using feedback to identify success stories and areas for improvement. |
3. Yes / No |
| 4. Do you plan to publicly report the collected information? Examples include: progress reports to EPA, summaries posted on the project/EPA website and public reports. If yes, please answer Question 5. If no, please proceed to Question 6. 5. When you report the collected information (e.g., in a progress report to EPA), do you plan to include Confidential Business Information (CBI) and/or Personally Identifiable Information (PII)? Please note that EPA does not expect to receive any CBI or PII when grantees report on their information collection activities. If you answer "Yes" to this question, please provide a clear and compelling justification for your choice, and note that your Project Officer will follow up to discuss this issue further. |
4. Yes / No If yes, justification: |
| 6. If you have any other plans for using the collected information that have not been listed here, please let us know about them. | 5. Additonal uses of collected information = |
| Congratulations -- you have made it to the end!! Please contact your Project Officer to let them know that you're done with the survey. They will send you a link to the online questionnaire, so that you may input your responses. (It's an extra step, we know, but the online survey will enable EPA to efficiently collate and review all 186 grantees' responses, which will give us more time to support your work.) Please note that the online questionnaire will ask you to provide the grantee name, the main point of contact, and their email address. Thank you again for taking the time to share your plans with us. Your input will strengthen EPA's Information Collection Request (ICR) submission for the EJCPS and EJG2G Programs. If you have any questions or need further information, please contact your Project Officer. |
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| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |