Home Based Primary Care Patient Satisfaction

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

TITLE OF INFORMATION COLLECTION:

Home Based Primary Care Patient Satisfaction (Oklahoma City & Lawton)

PURPOSE:

The purpose of this survey is to provide patient satisfaction information to leadership and staff on a quarterly basis, as there currently exists no other mechanism to capture this data within the customer service framework at the Oklahoma City VAMC. Additionally this survey includes questions which directly relate to patient care standards requiring a measure of success by The Joint Commission – Home Care.

DESCRIPTION OF RESPONDENTS:

Actively enrolled patients in Home Based Primary Care in Oklahoma City and Lawton.

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:__Karli Patterson_____________________________________

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 or Households	No. of Respondents	No. of Responses	Participation Time	Burden
VA Form 211014	50	4	8 minutes	27

FEDERAL COST: The estimated annual cost to the Federal government is $400.00

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? [X] 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?

The sample will include a percentage of each provider’s team to survey. Each quarter the Program Support Assistants will keep a running electronic spreadsheet of the patients that were sent surveys. This will provide a tracking mechanism within the service so that patients are not re-surveyed quarter after quarter.

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.

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