GenIC Request Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-0953)

T ITLE OF INFORMATION COLLECTION: SUNY – Stony Brook CCE WTC Health Program Customer Satisfaction Survey

PURPOSE:

The State University of New York (SUNY), Stony Brook is a Clinical Center of Excellence (CCE) in the World Trade Center (WTC) Health Program. We strive to provide the highest possible medical care and a comfortable patient experience. The purpose of this member survey to is to give all members an opportunity to rate their satisfaction with services provided at the Long Island CCE (SUNY). All members will have the opportunity to participate, whether or not they attended their yearly monitoring WTC Health exam.

Conducting this survey is a requirement of our Performance Work Statement. Feedback received through this customer satisfaction survey will help us improve our clinic experience. Survey results will not be published. Responses are intended only for internal review.

DESCRIPTION OF RESPONDENTS:

Respondents are 9/11 responders who participate in the WTC Health Program and are members of the Long Island Clinical Center of Excellence cohort. There are approximately 9,500 members who receive this survey. The average of our cohort is 54 years. Our members are approximately 10% female and 90% male. They can receive a yearly health monitoring exam as part of their WTC HP benefits. Approximately 60% are also certified with a WTC-related condition and as such are eligible to participate in the treatment program and receive medical care for their certified WTC-related conditions.

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:___Laurie Ishvak_____________________________________________

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

Personally Identifiable Information:

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

   1. This survey is anonymous, but we will offer members an opportunity to leave their name and contact information if they would like to be contacted by the WTC Health Program. This question is optional and responses will not be collected or saved beyond being used to contact interested members.

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
SUNY-cohort members	1,900	5 minutes	158 hours
Totals	1,900	5 min	158 hours

FEDERAL COST: The estimated annual cost to the Federal government is $15,000___________

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 have a cohort list that is refreshed and verified on a weekly basis. We will be surveying our entire membership and will use this cohort list. Participation in this survey is completely voluntary. Surveys will be mailed to members. Surveys will be self-administered and returned back to the CCE through the mail.

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

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