HEC Enrollment Survey

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

TITLE OF INFORMATION COLLECTION:

CBO HEALTHCARE ENROLLMENT SURVEY

PURPOSE:

VA wishes to conduct a local customer satisfaction surveys to advance VHA’s progress toward the goal of improving customer satisfaction at the local facility level. The VHA CBO goal is to provide an enrollment experience to Veterans that meets the needs of a diverse Veteran community.  VHA CBO seeks approval for this information collection that will allow Veterans an opportunity to provide anonymous feedback on how well the VHA enrolls new Veterans. 

Information gathered will determine where and to what extent new enrollee services are satisfactory, and where and to what extent they are in need of improvement. In addition, voluntary customer survey will not be used as substitutes for traditional program evaluation survey that measure objective outcomes.

To maximize the voluntary response rates, the information collections will be designed to make participation convenient, simple, and free of unnecessary barriers. Baseline data obtained through the VHA CBO Healthcare Enrollment information collections will be used to measure performance in the specific areas of the VHA Enrollment universe. Each data collection will consist of the minimum amount of information necessary to determine customer needs and to evaluate performance. The areas of concern to VHA and its customers change rapidly and it is essential to have the ability to evaluate customer concerns in a timely manner.

DESCRIPTION OF RESPONDENTS:

VA will conduct local surveying, designed to obtain patient perceptions of care at discreet levels of the organizations healthcare facilities. This survey solicits voluntary opinions and is not intended to collect information required to obtain or maintain eligibility for a Department of Veterans Affairs (VA) program or benefit.

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:_Dennis Boyette, Health Eligibility Center, Atlanta, GA

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 & Households	No. of Respondents	No. of Responses	Participation Time	Burden
VA Form 10-211013	1055	1.53	15	263
Totals				263

FEDERAL COST: The estimated annual cost to the Federal government is $3,500 per year.

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 random sample of New Enrollment Welcome letters mailed to New Enrollees Veteran eligibility for VHA healthcare benefits is categorized by Priority Groups. Each priority group has a pre-defined set of eligibility factors that determine the type of care Veterans in that priority group can receive. The sample will represent the percentage of new enrollees that are placed in each of the priority groups. The sample percentages will be derived from new enrollees for the most recent completed quarter in the Fiscal Year. The random sample for each priority group will be extracted from Enrollment System Redesign (ESR) via a randomized query. The sample size is 2110. It is expected that the response rate will be 50%. The data will not be generalized for any reasons.

This survey will be offered to Veterans on a monthly basis. The probability of Veterans having access to the public internet is unknown therefore the Veterans will receive a paper copy of the survey to complete. The survey will be distributed through U.S. Mail. VA, through the office of Quality and Performance, has expert staff available for advising, consulting, and working with individual facilities regarding local survey efforts.

Administration of the Instrument

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

[X] 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.

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