Generic Request_SORCC Spiritual Needs

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 2900-0770)
TITLE OF INFORMATION COLLECTION: Veterans Satisfaction Survey of Spiritual Care
needs and the level support being received.
PURPOSE:
This is a one-time survey to measure Veterans level of satisfaction with spiritual care services and
staff at the Veterans Affairs Southern Oregon Rehabilitation Center & Clinics in Home Base
Primary Care (VA SORCC HBPC). Surveys will help to guide spiritual care planning and offer
feedback to the Chaplain Service and staff to ensure spiritual care needs are being met and are of
the highest level of quality and satisfaction. The survey period will not exceed 45 days past the
approval to proceed.
Results will be reported to the following:
 The Nurse Professional Council
 Chief of Chaplain Service and Home Based Primary Care
 The Clinical Pastoral Education Advisory Committee.
 The Chief of Staff
 The Associate Director of Patient Care Services/Nurse Executive
DESCRIPTION OF RESPONDENTS: Veterans who receive services from the HBPC service
line of the VA Southern Oregon Rehabilitation Centers and Clinics (SORCC) in White City,
Oregon.
TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software)
[ ] Focus Group

[X] Customer Satisfaction Survey
[ ] Small Discussion 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: Chaplain Joe McMahan, M.Div., BCC. ACPE Certified Educator VA SORCC (692)
Email: [email protected]

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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

No. of
Participation
Respondents Time
200
2 minute

(1) Veteran Customers/Family

Burden
7 hours

Totals
FEDERAL COST: The estimated annual cost to the Federal government is _$100.00________
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?
[ 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?
Respondents are identified as Veterans who receive services from the VA SORCC HBPC and the
survey will be offered to all Veterans participating in HBPC. Respondents can exercise their
autonomy and decline to participate in completing the survey. Veterans will receive the
Satisfaction Survey either directly post an episode of care or at the end of a series of sessions of
care. Respondents will be provided a survey and an envelope in which the completed survey can
be sealed to preserve anonymity. Sealed envelopes will be returned to the Chaplain Service (MS
125) for tabulation.

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

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Instructions for completing Request for Approval under the “Generic
Clearance for the Collection of Routine Customer Feedback”
TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the
subject of the request. (e.g. Comment card for soliciting feedback on xxxx)
PURPOSE: Provide a brief description of the purpose of this collection and how it will be used.
If this is part of a larger study or effort, please include this in your explanation.
DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or
groups for this collection of information. These groups must have experience with the program.
TYPE OF COLLECTION: Check one box. If you are requesting approval of other
instruments under the generic, you must complete a form for each instrument.
CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the
collection will be returned as improperly submitted or it will be disapproved.
Personally Identifiable Information: Provide answers to the questions. Note: Agencies
should only collect PII to the extent necessary, and they should only retain PII for the period of
time that is necessary to achieve a specific objective.
Gifts or Payments: If you answer yes to the question, please describe the incentive and provide
a justification for the amount.
BURDEN HOURS:
Category of Respondents: Identify who you expect the respondents to be in terms of the
following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal
governments; or (4) Federal Government. Only one type of respondent can be selected per row.
No. of Respondents: Provide an estimate of the Number of respondents.
Participation Time: Provide an estimate of the amount of time required for a respondent to
participate (e.g. fill out a survey or participate in a focus group)
Burden: Provide the Annual burden hours: Multiply the Number of responses and the
participation time and divide by 60.
FEDERAL COST: Provide an estimate of the annual cost to the Federal government.
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. Please provide a description of how you plan to
identify your potential group of respondents and how you will select them. If the answer is yes,
to the first question, you may provide the sampling plan in an attachment.
Administration of the Instrument: Identify how the information will be collected. More than
one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or
facilitators (e.g., for focus groups) used.
Submit all instruments, instructions, and scripts are submitted with the request.
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