LHI Customer Service Fast Track Application

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-0953)

TITLE OF INFORMATION COLLECTION:

The Nationwide Provider Network Customer Satisfaction Survey

PURPOSE:

The World Trade Center (WTC) Health Program offers the Nationwide Provider Network (NPN) for members who reside outside of the New York City metropolitan area. Logistics Health Incorporated (LHI) administers the NPN. LHI connects members with trained medical providers in their local area to receive 9/11 related care.

LHI has a large clinical network that strives to provide the highest possible medical care and a comfortable patient experience. This customer satisfaction survey will evaluate aspects of our care, including: scheduling ease, wait times, and clinic cleanliness, and staff professionalism. Feedback received through the customer satisfaction survey will help us improve both our clinic and call center experience. Survey results will not be published. Responses are intended only for internal review.

DESCRIPTION OF RESPONDENTS:

Respondents will be adult patients who are members of the NPN. We will use a convenience sample of members during each phase of the monitoring exam appointment process and during their initial treatment appointment.

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: Laurie Breyer, Member Services Manager

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

Personally Identifiable Information:

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

Limited PII is being collected. Patients in the NPN are seen by a diverse “off-site” network of healthcare providers, relative to patients who are seen in the NY/NJ based CCEs. Having limited contact information enables us to address patient needs and concerns with their NPN healthcare provider in a timely manner.

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

3. If Applicable, has a System or Records Notice been published? [ X ] 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	No. of Respondents	No. of Responses per Respondent	Participation Time	Burden
Medical monitoring patients	2,100	3	4 minutes	420 hours
Total	420 hours

FEDERAL COST: The estimated annual cost to the Federal government is $14,500.

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?

We will use a convenience sample of members who are receiving medical monitoring through a NPN affiliated healthcare provider. We estimate three visits for medical monitoring patients. Participation in the survey is completely voluntary. Surveys will be mailed and self administered. Patients have the option to return the survey via mail, fax, or at their clinic.

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

[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.

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.

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.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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