Generic Request_COMM Patient Survey

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

T ITLE OF INFORMATION COLLECTION:

The Continuity of Medication Management (COMM) Patient Survey

PURPOSE:

The purpose of the proposed patient survey is to understand how medication beliefs vary between Durham VA patients with a single prescriber service of all chronic medications and Durham VA patients with two or more prescriber services. This survey will help us understand, for the first time, the challenges faced by patients and providers when multiple providers prescribe medications for patients with multiple chronic conditions. We are requesting an approval to conduct this survey to 2,000 patients who obtain healthcare services at the Durham VA medical center and have two or more of four chronic conditions because there are no extant patient surveys that ask the specific questions about medication beliefs and usage of non-VA pharmacy services that are critical to the successful completion of this survey study. We also need to conduct this patient services survey to capture information on patient factors that are not available in VA administrative databases, including smoking status, alcohol use, and functional status, reasons for medication non-adherence, education and income. If we did not capture these patient factors, our analysis of the association between the number of prescribers and medication adherence might be incorrect or biased. The collection of this survey will ensure that we have a good understanding of veterans’ medication beliefs and use of non-VA pharmaceutical services, and to ensure that we generate valid results from this survey.

DESCRIPTION OF RESPONDENTS:

The respondents are patients who obtain healthcare services at the Durham VA medical center and have two or more of four chronic conditions.

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:__Matthew L. Maciejewski, PhD___________________________________

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

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ x ] Yes [ ] No

Consistent with mail survey methodology that attempts to maximum response rates, we will be including a gift card worth $2 in the initial survey mailing. There will be no other payment or gifts to respondents.

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals or Households	1000	30 minutes	500 hrs
Totals	1000	30 minutes	500hrs

FEDERAL COST: The estimated annual cost to the Federal government is $2000 (Gift Card).

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?

See sampling Plan.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ x ] Telephone

[ ] In-person

[x] Mail

[ ] Other, Explain

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

Interviewers will be used in the rare instances when we need to conduct telephone follow-up to Veterans who did not complete mail surveys. We intend to send to them once again, following the current mail survey methodology.

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. 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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