Generic Clearance Request_VA Pittsburgh Research Survey

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

T ITLE OF INFORMATION COLLECTION:

Veteran Feedback Survey on Research at VA Pittsburgh

PURPOSE:

This 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 near future.

This anonymous, voluntary survey will be used to recognize and measure the wants/needs of Veterans we serve, and to establish a baseline understanding of general knowledge, awareness and engagement of the VAPHS Research Program from the typical/everyday population of Veterans who visit VAPHS University Drive Campus for any reason (e.g. receiving medical treatment, attending a standard or follow up appointment, accompanying someone to an appointment, etc.). The results of this survey will be incorporated in to developing more preferred/effective methods of communications about VAPHS medical research, enhance engagement, and improve the overall Veteran experience.

DESCRIPTION OF RESPONDENTS:

The surveys are intended to be completed by any/all Veterans in the geographical area served by the VA Pittsburgh Healthcare System, and will be available at VAPHS Research Office endorsed events.

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 [X] Other: Veteran Feedback Survey

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: Katherine Nega, BA, CCRC

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

The surveys will be located in an area that may also have giveaway items and informational documents/brochures with the VAPHS Logo. These giveaways will be available for any passerby to take, but will not be specifically offered as incentive for participating in the voluntary survey.

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals (Veterans)	100/year	3 mins	5
Totals	100	3	5

FEDERAL COST: The estimated annual cost to the Federal government is: The estimated annual cost is less than $5 (about the cost of half of a ream of paper to print the survey)

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?

The targeted respondents are any Veterans who visit VAPHS University Drive Campus for any reason (e.g. receiving medical treatment, attending a standard or follow up appointment, accompanying someone to an appointment, etc.).

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? [] Yes [X ] No

*A research staff member will be stationed at the table where the surveys are located. The staff member will not interview, facilitate or verbally administer the survey, but instead be available if a participant has questions.

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

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