Generic Clearance Request (OMB 2900-0770)_03.15.2017

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

TITLE OF INFORMATION COLLECTION: Veterans Experience Feedback

PURPOSE: This information collection instrument is a digital comment card for soliciting feedback on the experience of veteran patients of VHA facilities. Information gathered will be used only internally for service improvement and program management. Information submitted via this digital comment card will be used to identify early warning indicators of service failure via real time feedback that allows VA to resolve veterans’ issues, concerns, and/or questions in the moment at the point of service, thereby enabling local customer service recovery. Service recovery will be performed by VA employees reviewing and responding to feedback, if a response is requested by the veteran, in a 1:1 capacity. In addition, qualitative data collected in the comment card will be used by local facility leadership to identify opportunities for improvements in service delivery focused toward the experience of veterans, their families, and eligible dependents who are seeking or receiving care or services from that facility. Respondents choosing to use the digital comment card will do so on a voluntary basis, and information gathered will be used for local service recovery and improvement of local programs or processes within a VA medical facility. This comment card is not designed to yield statistically significant data, nor are the results intended to be generalizable to the population. By making the comment card available electronically, without requiring creation of a user account or log-in to access the comment card, VA seeks to streamline the process of providing feedback and reduce respondent burden for veterans and veteran advocates. The targeted respondent population is veterans who have received healthcare at a VA medical facility, and/or their advocates, who wish to provide qualitative feedback. Respondents are provided the option to “opt out” of follow up contact via selection of a yes/no radial button on the digital comment card. Respondents may choose to provide feedback that is positive, negative, or neutral in nature, by way of compliments, suggestions, or complaints. In addition to an end-user entering her/his service comment(s), the respondent will be requested to provide: first and last name, last four of social security number, phone number, and VA location or service that feedback is being provided about. This is the minimal information needed for service recovery efforts to occur – for the individual’s issue or complaint to be researched by a VA employee in order to assist in resolving that issue and improving service delivery to the veteran.

DESCRIPTION OF RESPONDENTS: Veterans and veteran advocates who wish to provide voluntary feedback on services or care provided at a VHA medical facility.

TYPE OF COLLECTION: (Check one)

[x] Customer Comment Card/Complaint Form [ ] 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:_Melanie West, Program Analyst ([email protected])_

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

Personally Identifiable Information:

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

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ x ] Yes [ ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ x ] 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 Respondents	Participation Time ( × minutes =)	Burden (÷ 60 =)
Individuals & Households	135	5	11
VA Form: n/a
Totals	135	5	11

FEDERAL COST: The estimated annual cost to the Federal government is $190.58 [$0 for printing/distribution, as this is a digital comment card; 135 responses x 5 minutes (300 s) x $16.94/hour (a Patient Advocate’s average grade of GS 7)], according to the January 2017 OPM General Schedule:  https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2017/GS_h.pdf

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions: N/A. This request is for a digital comment card.

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?

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.

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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