Justification

Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

(OMB Control Number: 2030-0051; EPA ICR Number: 2434.274)

TITLE OF INFORMATION COLLECTION: Cuyahoga County Board of Health Feedback Activity during Health Impact Assessment Training Sessions

PURPOSE: The information collected during the Health Impact Assessment Trainings will be used to gain feedback about the Healthy Urban Tree Canopy and Healthful Home programs.

Cuyahoga County Board of Health (CCBH) is requesting approval for our sub-awardee [The Ohio State University’s Health Outcomes and Policy Evaluation Studies (HOPES) program] to conduct a feedback activity during the Health Impact Assessment Trainings for CAB and community residents. We would like to collect this information so that the project’s Community Advisory Board (CAB) can gain feedback regarding environmental burdens faced by community members in East Cleveland, Euclid, and Maple Heights. Specific feedback activity mode and questions will be co-developed by the CAB. Potential survey modes include: 1) a traditional focus group model with interview questions, and/or 2) a storytelling activity using visual icons (a tool from OSU’s Public Engagement to Re-imagine Community Co-Planning framework). Regardless of mode, feedback activities will be up to 8 open ended questions and no identifying information will be collected other than region living in (East Cleveland, Euclid, or Maple Heights), years lived/worked in community (<1 yr, 1-5 yrs, 6-10 yrs, or >10 yrs), and age range (<18, 18-65, or >65 yrs old). The information gathered will not be used for the purpose of informing policy decisions but will likely be used to inform decisions about the Healthy Urban Tree Canopy and Healthful Homes program directions.

DESCRIPTION OF RESPONDENTS: Respondents individuals undergoing the HIA training sessions including project partners, CAB members, and community residents.

TYPE OF COLLECTION: (Check one)

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

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

[X] Focus Group [X] Other:

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

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden Hours
Individuals representing East Cleveland	50	10 min	8.33
Individuals representing Euclid	50	10 min	8.33
Individuals representing Maple Heights	50	10 min	8.33
Individuals (CAB/Project Partners)	30	10 min	5
Totals	180	10 min	30

FEDERAL COST: HOPES will review aggregate results and highlights of these surveys and convey findings to the CAB. Reviewing the data will not require any staff time that would not otherwise be dedicated to managing this award.

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? [ ] Yes [X] No

The potential group will be identified through partner and CAB resources (contacts, social media, communications, etc.) and included in the QAPP for this project.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[X] In-person

[ ] Mail

[ ] Other, Explain

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

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

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: Saphique Thomas

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