MHICM Consumer 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: MHICM Consumer Questionnaire

PURPOSE:

-To solidify feedback from MHICM participants with intent to make program improvements.

-To meet CARF Behavioral Health consumer satisfaction accreditation standards.

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

DESCRIPTION OF RESPONDENTS:

MHICM staff will distribute survey to Veterans enrolled in the MHICM 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/_Melissa Means RN _______________________________

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	~30	10	10
Totals	~30	10	10

FEDERAL COST: The estimated annual cost to the Federal government is none_____

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?

MHICM staff will distribute the satisfaction survey every six months to Veterans enrolled in the MHICM Program.

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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