Veteran Appointment Mobile Application Satisfaction Survey request

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

TITLE OF INFORMATION COLLECTION:

Veteran Appointment Mobile Application Satisfaction Survey

PURPOSE:

In support of the VA’s mission to create a modern, efficient, and customer-friendly interface that all Veterans will enjoy, the VA Innovation Initiative (VAi2) is planning on piloting a Veteran Appointment Request mobile application at four medical centers. This application is an extension to the VA’s service delivery that will allow Veterans the ability to request clinical appointments using their mobile devices. To ensure the functionality is effective and meeting the needs of patients, the VA would like to conduct a customer satisfaction qualitative survey of Veterans participating in the pilot.

The short survey will ask Veterans to rate the ease of use and their overall experience with scheduling their appointments using the enhanced functionality. The survey results will be assessed to help inform internal VA subject matter experts to the efficiency and effectiveness of the functionality and provide insights into whether improvements need to be made.

DESCRIPTION OF RESPONDENTS:

Potential survey respondents will be patients and caregivers participating in a pilot of the mobile Veteran Appointment Request application. The pilot is being administered at four Veterans Affairs Medical Centers and will include a total of 400 participants.

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:____ Ferenc Ayer ________

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	No. of Respondents	Participation Time	Burden
Individuals (VA Patients participating in a pilot at four VA Medical Centers)	400	5 minutes	33 Hrs
Totals	400	5 minutes	33 Hrs

FEDERAL COST: The estimated annual cost to the Federal government is __ $8,593.51__

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? [Y ] 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 list of 100 voluntary participants will be obtained from each of the four VA Medical Centers that are part of the VA Veteran Appointment Request pilot. Since the total number of participants is limited to 400, the sampling plan will include all participants.

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

[ ] 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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