OHS Customer Survey Generic Clearance Submission

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0420-0545)

TITLE OF INFORMATION COLLECTION:

Office of Health Services Medical Clearance Process Customer Satisfaction Survey

PURPOSE: To collect, collate and analyze responses to a customer satisfaction survey that will allow Peace Corps’ Office of Health Services to look for commonalities or trends which would indicate the need for process improvements or changes. The results would also assist in identifying needs in areas of improvement in staff education and customer service delivery. We will be trending results to pinpoint problem areas that we can focus our quality improvement efforts on.

DESCRIPTION OF RESPONDENTS:

Peace Corps applicants who have completed the medical clearance process with a determination of medically cleared or medically not cleared.

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: Denora Miller, FOIA/Privacy Act Officer

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 [ X ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [X ] 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	500	5 minutes	42
Totals	500	5 minutes	42

FEDERAL COST: The estimated annual cost to the Federal government is $300.

Administrative Assistant @ $20/hr. x 15/hours/fiscal year =$300.

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?

We will contact Peace Corps Invitees who have completed the medical screening determination process. Utilizing Survey Monkey we will send the messaging and link to them after their final medical determination but before they have left for country. We have determined that we can achieve a confidence level of 95% if we survey around 500 invitees in FY 2015. The sample size would have to be adjusted annually to capture the correct proportion of overall determinations made.

Administration of the Instrument

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

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

[ ] Telephone

[ ] In-person

[ ] 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.

3