Justifiication

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: 2434.278)

TITLE OF INFORMATION COLLECTION: Feedback Survey: NWEJC Launch Event

PURPOSE: To get feedback about how the launch event went to help us learn from this event and help us to plan future events and engagement with the Northwest Environmental Justice Center. The feedback will provide us with the information needed to designed informed events over the five year project period. The survey results will give us an opportunity to ensure we produce events that are useful to communities.

DESCRIPTION OF RESPONDENTS: About 150 people representing various CBOs, Tribes, philanthropic organizations, state and federal agencies.

TYPE OF COLLECTION: (Check one)

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

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

[ ] Focus Group [ ] Other: ______________________

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

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

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals/households	85	5 minutes	7.08 hours
Private Sector	10	5 minutes	.83 hours
State, local, or tribal governments	40	5 minutes	3.33 hours
Totals	135	5 min	11.24 hours

FEDERAL COST: The estimated annual cost to the Federal government is: $ 0

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

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?

We plan to identify our respondents as the group of people who attend our live in person launch event on April 30th. Through a QR code to a digital survey and paper surveys, all people at the event will be invited to optional participate in the feedback survey.

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? [ ] Yes [X ] 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: Esther Sosa

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