CWT IT Consumers Generic Request

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

TITLE OF INFORMATION COLLECTION: Incentive Therapy Internal Consumer Satisfaction

PURPOSE:

• To solidify feedback from Incentive Therapy participants with intent to make program improvements.

• To meet Commission on Accreditation of Rehabilitation Facilities Behavioral Health consumer satisfaction accreditation standards.

• Quarterly surveys will be tallied for quarterly and annual review, action and analysis.

DESCRIPTION OF RESPONDENTS:

Therapeutic & Supported Employment Services staff will distribute survey to Veterans enrolled in the Therapeutic & Supported Employment Incentive Therapy Program at the Danville Medical Center, Danville IL.

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:___/s/ Johanna Willemse, LCSW_______________________________________

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	~120	10 minutes	20
Totals	~120	10 minutes	20

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? [ 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?

Therapeutic & Supported Employment Services staff will distribute the satisfaction survey quarterly to Veterans enrolled in the Therapeutic & Supported Employment Incentive Therapy Program during an Incentive Therapy meeting at which approximately 30 or less Veterans will be in attendance.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ x ] In-person

[ ] Mail

[ ] Other, Explain

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

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