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: 2434.281)

TITLE OF INFORMATION COLLECTION: Feedback survey for participants of Healthy Homes and ECO Neighborhoods’ learning experiences

PURPOSE: The survey is voluntary, and it hopes to capture participant feedback from the learning experiences (i.e. presentations, workshops) provided as part of the Healthy Homes and ECO Neighborhoods program. Participants who also receive a Healthy Homes assessment and energy audit will be asked to provide additional feedback on their experience with that portion of the program. By completing the survey, participants are agreeing that their anonymized responses may be used in reporting and communicating with the project’s partners including Clean Wisconsin, Sherman Park Community Association, City of Milwaukee, and the EPA. The demographic information about participants will be used to ensure our programming reaches diverse audiences in our target neighborhoods. Participants may choose not to provide this information as it is voluntary.

DESCRIPTION OF RESPONDENTS: Our respondents will be residents of the target neighborhoods we are engaging within the following zip codes: 53210, 53216, 53208, 53206, 53209, 53204, 53207, 53215 who have participated in a Healthy Homes and ECO Neighborhoods’ learning experience.

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 or Households	1200	5 - 15 mins	100 – 300 hours
Totals	1200	5 -15 mins	100-300 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?

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

[X] In-person

[ ] Mail

[ ] Other, Explain

We will use google forms to administer the surveys in person or through a survey link (if the experience is virtual) at the end of the learning experience.

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

The learning experience facilitators will direct participants to fill out the survey at the end of the experience.

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: Jesse Casiano

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