IOM Generic Clearance Request

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

TITLE OF INFORMATION COLLECTION:

Interview and Discussion Group Protocols for the Institute of Medicine Evaluation of the Department of Veterans Affairs Mental Health Services

PURPOSE:

Sponsored by the Department of Veterans Affairs (VA), the Evaluation of the VA Mental Health Services project is mandated in Section 726 of the FY 2013 National Defense Authorization Act (NDAA). The VA has tasked an Institute of Medicine (IOM)-appointed committee to carry out the project with the goal of assessing the quality of the mental health care being provided to veterans of the Iraq and Afghanistan wars. The committee’s recommendations will assist the VA to improve not only the quality of mental health care services for these veterans, but also veterans’ access to VA mental health services.

The legislation directs the IOM committee to assess the quality of the mental health care being provided to such veterans (including the extent to which veterans are afforded choices with respect to modes of treatment) through site visits to facilities of the Veterans Health Administration (including at least one site visit in each Veterans Integrated Service Network [VISN]).

The IOM will conduct site visits in each of the 21 VISNs where veterans receive their mental health care. The purpose of the site visits is twofold: First, to determine the quality of the mental health care being provided, including the extent to which veterans are afforded choices with respect to modes of treatment; and second, to learn why some VA-eligible veterans are not seeking mental health services through VA facilities.

See accompanying statement of task for a complete description of the IOM study.

DESCRIPTION OF RESPONDENTS:

The respondents for the site visits consist of the following

• Veterans who are currently receiving mental health services at the VA facility;

• Veterans who are not using VA mental health services;

• Family members or friends of veterans not seeking mental health services;

• Community-based service providers, including peer support specialists;

VA staff, such as behavioral health service providers and administrators, also will be respondents for the site visits.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [x] Small Discussion Group

[ ] Focus Group [x ] Other: One-on-one interviews

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:_Abigail Mitchell________________________

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

*Respondents’ contact information, such as name and phone number, will be obtained for scheduling purposes only and will be excluded from any data to be analyzed.

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 ( × minutes =)	Burden (÷ 60 =)
Individuals or Households	1200	60	1200
Private Sector	450	60	450
Federal Government	650	60	650
Totals	2300	138,000	2300

FEDERAL COST: The estimated annual cost to the Federal government is $0.

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 [x] 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?

Site visits will be conducted at VA medical centers (VAMC), outpatient clinics, and Vet Centers where Veterans of the Iraq and Afghanistan wars seek psychiatric services and psychosocial supports. Site visit activities will also occur in non-VA settings that may be providing mental health services to Veterans, such as in community clinics, organizations that may provide peer supports, local Veterans Service Organizations, among others.

Veterans will be recruited via outreach to various patient liaisons, including clinical staff working with the Returning Service Members program, the Program Manager for Women Veterans, and the Mental Health Consumer and Advocate Council for each VAMC. Veterans not seeking VA services will be recruited through contacts made during the conduct of the environmental scan of the communities in which the VISNs are located.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[x] Telephone

[x] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [x] Yes [ ] 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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