Generic Request - CRT

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

TITLE OF INFORMATION COLLECTION:

Congressional Response Team Customer Satisfaction Survey

PURPOSE:

The Veterans Health Administration Office of Community Care (VHA OCC) will use the information gathered as a result of this survey to focus specifically on the satisfaction of the United States (U.S.) Congressional offices with the VHA OCC Congressional Response Team (CRT), in order to identify problems or complaints that require attention and to improve the quality and selection of services delivered to U.S. Congressional offices by CRT.

The resulting data will be used to demonstrate that CRT is providing timely, high-quality services to U.S. Congressional offices and to measure improvement in the efficiencies of CRT processes and communications toward the goal of meeting or exceeding internal benchmark performance.

DESCRIPTION OF RESPONDENTS:

The pool of respondents will consist of a sampling of all U.S. Congressional offices to include all offices representing members of the House of Representatives and the U.S. Senate.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [] 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: Douglas Katason, Stakeholder Outreach Manager

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [] 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 [] No

BURDEN HOURS

Category of Respondent: Individuals & Households	No. of Respondents	Participation Time	Burden
VA Form 10-XXXXXX (Congressional Response Team Satisfaction Survey)	110	5 minutes	9

FEDERAL COST: The estimated annual cost to the Federal government is $896.00.

Cost includes burden hours ($216.00) plus email preparation and processing of the survey ($680.00).

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 [ ] 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?

Inclusion criteria:

Sampling will be from all U.S. Congressional offices that interact with CRT regarding issues or concerns raised by their Veteran constituents about health care administered by VHA OCC.

Sample size:

The sample size will be approximately 552 U.S. Congressional offices. It is anticipated that there will be an estimated response rate of 20 percent. The Congressional offices email addresses will be obtained by utilizing existing public records and databases, in addition to existing contact information retained by CRT. Email addresses will be utilized in accordance with existing VA approved standards ensuring privacy and security of the data.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

A survey invitation email will be sent to the 552 U.S. Congressional offices. The invitation email will contain a Web link to the VA Community Care Web site in order to access the survey instrument which resides in the Web-based survey tool, Survey Monkey.

A survey reminder email will also be sent to the same sampling of U.S. Congressional offices approximately two weeks after the invitation was sent to either remind the recipient to take the survey or thank them for taking the survey.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

4