OMB Submission Form -- Customer Satisfaction with the 2012 Guide to Clinical Preventive Services

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0935-0179)

T ITLE OF INFORMATION COLLECTION: Customer Satisfaction with the 2012 Guide to Clinical Preventive Services

PURPOSE:

The Guide to Clinical Preventive Services has consistently been a highly popular publication as we have distributed semi-annual editions over the past 10 years. It is a pocket-sized booklet containing recommendations from the US Preventive Services Task Force for about 80 individual preventive health topics. Although we have received unsolicited feedback about the utility of the Guide, we feel that inviting feedback on customer satisfaction with the product at this time would be helpful. Particularly with a change in the page layout for the individual recommendations included in the book, we want to determine whether it is meeting expectations, getting to the audience we intend, and fulfilling their information and implementation needs. The goal of this project is to receive feedback about the document itself and not with the specific recommendations or guidelines.

To achieve this goal the following data collection will be implemented:

• Guide to Clinical Preventive Services Feedback Questionnaire (see Attachment A) – the purpose of this questionnaire is to solicit feedback from users of the 2012 Guide to Clinical Preventive Services. In addition to questions about how the Guide is used and improvements users would like to see, questions are asked about the use of the printed Guide verses the online Guide. All recipients of the Guide will be notified of the online survey by a card inserted into the publication.

DESCRIPTION OF RESPONDENTS:

Respondents will be persons that use the Guide and include primary care clinicians (physicians, nurse practitioners, physician assistants, osteopaths, nurses, etc.), health professions educators, residents and students in clinical curricula, policymakers, health care system administrators, and others.

TYPE OF COLLECTION: (Check one)

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

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

[] Focus Group [ ] Other: ______________________

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: Corey Mackison

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

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [ ] No

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

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?

[ ] Yes [ ] No

Category of Respondent: Private Sector

The Guide to Clinical Preventive Services Feedback Questionnaire will be completed by 5,000 users of the Guide and takes 2 minutes to complete for a total of 167 burden hours.

BURDEN HOURS

Form Name	Number of Respondents	Number of responses per respondent	Hours per response	Total burden hours
Guide to Clinical Preventive Services Feedback Questionnaire	5,000	1	2/60	167
Totals	5,000	na	na	167

FEDERAL COST: The estimated annual cost to the Federal government is: $1,560

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 [ ] 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?

Potential respondents will be people who receive the 2012 Guide to Clinical Preventive Services either by ordering a copy from the AHRQ Clearinghouse or by picking up a copy at an exhibit booth or meeting venue. We plan to print 25,000 copies of the publication and will insert a card into each one to announce the online survey and provide the URL. Given the high level of interest that users have in the Guide a response rate of 20 percent is expected.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

List of Attachments:

Attachment A -- Guide to Clinical Preventive Services Feedback Questionnaire