VA Generic Clearance Submission PC3 Survey

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

TITLE OF INFORMATION COLLECTION:

Patient Centered Community Care (PC3) Veteran Survey

PURPOSE:

The overall purpose of the PC3 Veteran surveys are to systematically obtain information from patients that can be used to identify problems or complaints that need attention and to improve the quality of purchased care services delivered to Veterans.

The resulting data will be used to demonstrate that VA is providing timely, high quality health care services to patients and to measure improvement toward the goal of matching or exceeding VHA internal benchmark performance.

DESCRIPTION OF RESPONDENTS:

The pool of respondents will consist of a monthly, random sample of Veterans who have received non-VA care from a PC3 program provider within all Veteran Integrated Service Networks (VISN). The respondents will be contacted within 60 days of receiving the non-VA services.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [] 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: Douglas Katason

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

Personally Identifiable Information:

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

BURDEN HOURS

Category of Respondent: Individuals & Households	No. of Respondents	Participation Time	Burden
VA Form 10-211009	2,000	5 minutes	167
Totals			167

FEDERAL COST: The estimated annual cost to the Federal government is $38,200.

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 [ ] 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?

Inclusion criteria:

• Sample size is fixed at each VISN by service

• Samples selected from all Veterans that received PC3 program services within 60 days of each monthly data extraction

• Veterans receiving a PC3 Veteran survey in the previous 12 months are excluded.

Sample size:

Surveys will be sent out monthly based on a tiered number for each PC3 program region based on PC3 program utilization. It is anticipated that approximately 830 surveys will be sent out monthly with an estimated response rate of 20%. The patient names, addresses, services received, dates of service, and scrambled social security numbers will be extracted from internal VA databases in accordance with existing approved standards ensuring privacy and security of the data. Note that the scrambled SSNs are used internally to help ensure multiple survey requests are not sent to a patient with a 12 month period.

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

[ ] Mail

[ ] Other, Explain

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

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

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