Caregivers_FastTrackClearance_100219

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

TITLE OF INFORMATION COLLECTION:

CSignals Caregiver Comment Card

PURPOSE: VEO will conduct this survey on attendees at the 2019 Association of the United States Army National Convention on October 14-16, 2019 who identify as caregivers to obtain data on their experiences as caregivers in the VA. The data collected will be used for internal community process improvement activities.

DESCRIPTION OF RESPONDENTS:

• The target population is 2019 Association of the United States Army National Convention attendees who identify as caregivers.

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:
Anil Tilbe
[email protected]

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 Respondents	Participation Time	Burden
Individuals	300 Annual	2 minutes	10 hours
Totals	300 Annual	2 minutes	10 hours

FEDERAL COST: The estimated annual cost to the Federal government is 0 because we will are using the same survey infrastructure and support personnel that are used for the existing Community Engagement Digital Comment Card.

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? [] 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?

This survey is a set of questions that seeks to obtain data directly related to caregivers and will be administered to caregivers at the 2019 Association of the United States Army National Convention on October 14 – 16. While caregivers are a subset of the types of people eligible for the survey, there is not a defined population for this subset. Therefore, there will be no sampling of respondents at the event (all attendees will have the opportunity to respond). These questions will be administered using a link to an online survey instrument in the VSignals reporting tool. Event attendees will be invited to provided their responses using the link on Ipads manned by event personnel. The link will be opened for the duration of the event and 3 days after the close of the event for any service recovery, upon which it will be turned off. It is expected that 300 event attendees will respond. The data will be transmitted to the VSignals database and the unweighted data will be presented on dashboards in the VSignals analysis tool.

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

[ ] Mail

[X] Other, Explain: E-mail

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

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

Survey Questions (please also see attached for a mockup of formatting)
No.	Question	Response Type
1	Which of the following factors influenced your decision to seek emergency medical care at <Division Name>? Select all that apply. The distance to <Division Name> was convenient. The wait to see an outpatient provider was too long. The outpatient clinic didn't have the specialty I needed. I was worried about receiving bills if I went to a community ER. I trust the VA to take care of me. I had an emergency medical need.	Multiple choice checkboxes; respondent can select multiple checkboxes.
2	When I arrived at the front desk of the <ER / Urgent Care>, I was treated with compassion and respect.	Likert Scale
3	Once my clinical treatment began, the <ER / Urgent Care> healthcare team checked in with me regularly and kept me in the loop.	Likert Scale
4	Once my clinical treatment began, the <ER / Urgent Care> healthcare team listened to my concerns and showed they cared.	Likert Scale
5	The <ER / Urgent Care> healthcare team made it easy for me to understand my discharge instructions.	Likert Scale
6	A plan for future outpatient appointments was clearly communicated to me prior to discharge.	Likert Scale
7	Overall, the <ER / Urgent Care> was comfortable and clean.	Likert Scale
8	Overall, I feel my wait times were reasonable.	Likert Scale
9	Overall, I was satisfied with the service during my <ER / Urgent Care> visit.	Likert Scale
10	Based on this <ER / Urgent Care> visit, I trust the <Division Name> <ER / Urgent Care> to serve me in the future.	Likert Scale

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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