Non-VA Care Coordination Veteran Satisfaction Survey

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

TITLE OF INFORMATION COLLECTION:

Non-VA Care Coordination Veteran Satisfaction Survey

PURPOSE:

The Non-VA Care Coordination Veteran Satisfaction Survey is to be conducted as part of the national deployment plan of the Non-VA Care Coordination (NVCC) Initiative. NVCC was chartered by VHA to improve and standardize the process by which Veterans were referred for non-VA care services and the coordination of that care. The design and implementation of the NVCC process is led by the Chief Business Office and supported by VISN 11 VA Center for Applied Systems Engineering.

The Non-VA Care Coordination Veteran Satisfaction Survey is a point-in-time survey and will be administered only one time. The survey’s purpose is to assess Veteran satisfaction with receiving non-VA care services through the NVCC process as compared to obtaining non-VA care services through Fee basis processes utilized by VA medical centers prior to the implementation of NVCC.

DESCRIPTION OF RESPONDENTS:

The national deployment strategy for NVCC is for CBO to train one “champion site” per VISN. The champion sites will be responsible to disseminate the NVCC process to the remaining sites in their VISN. The pool of respondents will be a sample of Veterans from each of the 21 champion sites who obtain authorized non-VA care during the month of April 2012. By April 2012, approximately 11 VISN champion sites will have received training by CBO and will have implemented the NVCC process. The remaining 10 champion sites will not have implemented NVCC and, therefore, this pool of Veterans will have received non-VA care through pre-existing Fee for service basis processes. The sample of Veterans from each VISN champion site will receive the survey in the mail during the week of July 9, 2012.

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: Amy Vannatter-Dorr

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	Participation Time	Burden
VA Form 10-0545	7980	5 minutes	665
Totals			665

FEDERAL COST: The estimated annual cost to the Federal government is: $6,800

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?

• Target Population

• Veterans from 21 VISN champion sites who receive authorized non-VA care during the month of April 2012

• Sample from Target Population

• An overall sample size of 7980 Veterans from the target population

• Overall sample size based on FY11 total number of Outpatient Fee Uniques

• Anticipated response rate of 30% (target 2400 completed surveys)

• A sample of 380 Veterans will be randomly selected from the target population at each of the 21 VISN champion sites

• The Veteran names, addresses, date of non-VA care service, type of service, and referral date will be extracted from internal VA databases in accordance with existing approved standards ensuring privacy and security of the data

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 – Cover letter, survey instrument, and a self-addressed, stamped envelope

[ ] 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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