Generic Request OKC Dental Satisfaction Survey

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 2900-0770)
TITLE OF INFORMATION COLLECTION:

Oklahoma City (OKC) VAMC Dental Patient Satisfaction Survey
PURPOSE:

The purpose of the OKC Dental Patient Satisfaction Survey is to survey patients
receiving care or treatment services by all types of VA staff and provide feedback
for process and provider improvement, thus increasing customer satisfaction.
DESCRIPTION OF RESPONDENTS:

Respondents are OKC VAMC eligible patients. The patients will consist of
established and new patients receiving various types of dental care.
TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[X] Customer Satisfaction Survey
[ ] Small Discussion 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: Colleen Whorton, Administrative Officer OKCVAMC
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 [X] No
3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No

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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
Participation
Respondents Time

VA Form 10-211008

2400

Burden

15 minutes

600
600

Totals

FEDERAL COST: The estimated annual cost to the Federal government is $75.00 for copier
paper and ink.
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?

This data collection will equally survey all dental provider patients to provide
anonymous feedback for process improvement.
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.

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