Neurology/Rehabilitation Inpatient Program Satisfaction Survey

Generic Request_Neuro Rehabilitation Satisfaction Survey.docx

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)

Neurology/Rehabilitation Inpatient Program Satisfaction Survey

OMB: 2900-0770

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RShape1 equest for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 2900-0770)

TITLE OF INFORMATION COLLECTION:

Neurology/Rehabilitation Inpatient Program Satisfaction Survey


PURPOSE:

This is a voluntary survey about our Veteran’s experience with the Neurology/Rehabilitation Clinic. The ratings will help improve our service to Veterans and their families. There is also a requirement by the Commission on Accreditation of Rehabilitation Facilities (CARF) to survey Neurology/Rehabilitation patients regarding their patient satisfaction.


DESCRIPTION OF RESPONDENTS:

Respondents will be patients receiving treatment in the Neurology/Rehabilitation Inpatient Program


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: Alisha N. Cornelius


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 and Households

No. of Respondents

Participation Time

Burden

Neurology/Rehabilitation Inpatients

240/year

5 minutes

20

VA form 10-0546




Totals



20


FEDERAL COST:

This survey will be distributed with the CARF orientation, picked up at discharge and collated by the rehabilitation Physician Assistant (PA) every month. It will take no more than 1 hour monthly to collate and document data which will be reviewed by the rehabilitation team for opportunities for improvement in our performance improvement program. It is estimated that this task alone will require no more than $51,140 monthly to do the collation and data entry and presentation to the rehabilitation team. The cost for paper is $15/year.


The estimated annual cost to the Federal government is: $51,155.00.


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?


Veterans receiving treatment with the Neurology/Rehabilitation Clinic will be given a voluntary survey after their clinic appointment.


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

  1. 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”

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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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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleDOCUMENTATION FOR THE GENERIC CLEARANCE
Author558022
File Modified0000-00-00
File Created2021-01-31

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