Office of Mental Health Veteran Satisfaction Survey

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 2900-0769)

TITLE OF INFORMATION COLLECTION:

Office of Mental Health Veteran Satisfaction Survey (Form 10-10129)

PURPOSE: To identify and better understand barriers that may be inhibiting Veterans’ access to VHA mental health services. Survey results will be used by local VA medical centers to obtain Veteran feedback in an efficient, timely manner in order to promote improvements in mental health service delivery. Survey data will provide insight into Veterans’ perceptions and experiences with mental health care and will allow such feedback to contribute directly to program improvements in service.

DESCRIPTION OF RESPONDENTS:

Respondents will be Veterans receiving outpatient mental health services

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:__Dr. Rani Hoff___

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: Individuals or Households	No. of Respondents	Participation Time	Burden
VA Form 10-10129	10,000	15 minutes	2500 hr
Totals			2500 hr

FEDERAL COST: Cost estimates for this survey are based on actual costs for FY16.

	Equipment Maintenance	GS Salaries	Supplies	USPS (return postage)	Out-going Postage	Data Entry	TOTAL
Costs	1,000	326,503	4,000	11,600	25,970	38,535	407,608

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?

The survey will be mailed to Veterans who are receiving VA outpatient mental health services. The survey will be implemented during a select timeframe, at all medical centers.

Potential respondents will be identified based on encounters in VA outpatient mental health clinics as recorded in the VA Corporate Data Warehouse. Patients who received VA outpatient mental health services within a designated time window will be identified and contact information will be obtained from their medical records. This contact information will be used to mail out surveys. To allow assessment of bias in survey responses, and to allow for examination of differences in survey response based on patient characteristics, we will maintain a crosswalk linking the survey # to the scrambled social security number of the potential respondent. However, we emphasize that the surveys themselves will not include any personally identifiable information.

To inform evaluation of a major team-based mental health care initiative to improve patient access to services, we will stratify the sample of potential Veteran respondents into Veterans who were versus were not assigned to a general mental health team. As part of this pilot initiative, all facilities are required to set up one general mental health team to treat patients. Team assignment will be determined based on data from the PCMM tables of the VA Corporate Data Warehouse at the time the sample is pulled. Half of the surveys mailed will be to Veterans on a team. The other half of surveys mailed will be to Veterans receiving standard VA general mental health services (i.e. not on a team).

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

[X] Mail

[ ] Other, Explain

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

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

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