PVAMC Generic Request

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

T ITLE OF INFORMATION COLLECTION:

Patient Satisfaction Survey for Portland VAMC Low Vision Clinic

PURPOSE:

The information will be used to help improve the quality of our services. Patients’ answers will direct our care in appropriate, patient-centered, directions, and let us know which areas are not meeting the needs of the patients. Also, it is a requirement for CARF accreditation.

DESCRIPTION OF RESPONDENTS:

Patients that attend the PVAMC Low Vision Clinic will be provided this survey at the end of their clinic visit. They can fill it out and turn it in at the end of the visit (voluntary). If they need help a family member or friend can help them. If they ask, a staff member, who is not a health care provider can assist them in filling out the form.

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: Megan Gobble, RN BSN ([email protected])

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	No. of Respondents	Participation Time	Burden
Individual	200	11 minutes	36.66
Totals	200	11 minutes	37 hrs

FEDERAL COST: The estimated annual cost to the Federal government is estimate at $16.33 of a GS-5 per year x 360 minutes (6) hours for administering the survey = 19,596 and $10 per 200 paper copies) = $19,606.

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?

All patients that attend the clinic will be provided this survey at the end of their visit. We estimate about 200 of them will fill it out and return it to us at the time of their visit.

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 (if patient decides not to stay and fill out at the time)

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [ X ] No*

* Help will be provided if patient requests assistance.

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

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