Survey of Veterans' Satisfaction with the Income Verification Process Service

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

T ITLE OF INFORMATION COLLECTION:

Survey of Veterans' Satisfaction with the Income Verification Process Service

PURPOSE: The Health Eligibility Center’s (HEC) goal is to gather information about Veteran’s Income Verification experiences.  HEC will gather strictly qualitative information for internal use by providing an opportunity for our customers to voluntarily respond to a brief questionnaire. This information will not be released outside of the agency. The Income Verification Process is used to ensure that a sub set of Veteran’s are in the correct Priority Group (PG). Priority Group is the primary criteria used to determine eligibility for VHA benefits. This questionnaire will assist Income Verification in meeting the Department’s vision to provide Veterans the world-class benefits and services they have earned - and to do so by adhering to the highest standards of compassion, commitment, excellence, professionalism, integrity, accountability, and stewardship. HEC seeks approval for this information collection that will allow Veterans an opportunity to provide anonymous feedback on how the Income Verification process is perceived by Veterans that have been through the Income Verification Process.  HEC will only use this feedback to improve the process. The data collected will consist of the minimum amount of information necessary to determine customer needs and to evaluate performance. In addition, this questionnaire will not be used as substitutes for traditional program evaluation surveys that measure objective outcomes. This collection is non-controversial and will not raise any concerns to other Federal Agencies. Results will not be used to substantially inform influential policy decisions. No personally identifiable information will be collected. The data collected will not be generalized to the population of the study. To maximize the voluntary response rates, the information collections will be designed to make participation convenient, simple, and free of unnecessary barriers.

DESCRIPTION OF RESPONDENTS: The target Veteran population includes Veterans that are currently classified in Priority Group 5. Priority Group 5 Veterans receive free or discounted health care from VHA. PG5 Veterans complete an annual Means Test (OMB 2900-0091) providing VHA with an estimate of their annual household income. If the self reported income is below the national means test threshold, the Veteran is eligible for free or discounted care. Veterans that receive Income Verification correspondence asking them to verify their income are the respondent pool for this questionnaire.

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: Tony A. Guagliardo

Director

Health Eligibility Center

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 and Households	No. of Respondents	No. of Responses	Participation Time	Burden
VA Form 10-0541	2000	1	6 minutes	200 hours
Totals				200 hours

FEDERAL COST: The estimated annual cost to the Federal government is to process form survey form 10-0541 is $3200.00.

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?

A randomized sample will be pulled from the Enrollment Database. The sample will be comprised of Veterans that have been through adjudication and will reflect the actual percentages of Veterans that remained in PG5 or were moved to another PG once adjudication
is complete.

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.

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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