Spinal Cord Injury Patient Care Survey

R equest for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 2900-0770)

TITLE OF INFORMATION COLLECTION:

Spinal Cord Injury Patient Care Survey

PURPOSE:

The intended purpose of collecting this information is to ensure that Commission on Accreditation of Rehabilitation Facilities (CARF) program is responsive to the needs of the person served and to the legal requirement of information. The information collected will assist in providing feedback in order to determine necessary changes, additional measures and performance improvement to exceed patients’ expectation. VHA requests the ability to obtain feedback by survey for the purposes of determining if the project is meeting the objectives and intent set identified in Executive Order 13410, assessment of the relevancy and usability of the information provided to beneficiaries, enrollees and providers on selected health care measures. As additional measures are added or reports change, additional feedback will be needed.

DESCRIPTION OF RESPONDENTS:

The information is collected from spinal cord injury patients and will be used by Spinal Cord Injury (SCI) Providers and other Disciplines who are involved in patient care. Any input or information received from patients will be used to improve care and patient needs in addition to patient satisfaction.

The input of families and patients is sought in preparing and adapting materials to meet their needs and the needs of families/support systems entering into the rehabilitation process in the future. This input process engages all parties in a sense of a shared future that promotes long-term organizational excellence and optimal outcomes. CARF-accredited organizations continually focus on the expectations of the persons served and other stakeholders. CARF standards direct the organizations focus to soliciting, collecting, analyzing and using input from all stakeholders to create services that meet or exceed the expectations of the persons served, the community and other stakeholders.

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: ______________

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: Fatima Harkous

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 Individuals & Households	No. of Respondents	Participation Time	Burden
VA Form 10-0515	200	10	33
Totals			33

FEDERAL COST:

The estimated annual cost of printing VA Form 10-0515 is $2,025.

SCI coordinator: $32.00/per hr processing x 120 min. x 200 / 60 = $12,800.00.

SCI Secretary: $21.00/hr x 200 x 15 minutes per questionnaire / 60 = $1050.00.

The total cost to the Federal Government is $15,875.00.

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?

The program requires us to use an “instrument tool” to measure satisfaction and feedback gathered from the patients served.

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

[X] 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.

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Submit all instruments, instructions, and scripts are submitted with the request.

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