GenIC Request

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

TITLE OF INFORMATION COLLECTION: NYC Health + Hospitals World Trade Center Environmental Health Center Customer Satisfaction Survey

PURPOSE: The World Trade Center Environmental Health Center (WTC EHC) holds contracts with the WTC Health Program to operate the Survivor Clinical Center of Excellence (CCE) Program and the Survivor Data Center (DC). The WTC EHC includes three clinical sites in the NYC Health + Hospitals system: Bellevue Hospital, Elmhurst Hospital, and Gotham Health, Gouverneur. As required by the Zadroga Act, the CCE is mandated to conduct a customer satisfaction survey. Results from the survey will be used to improve the patient experience.

DESCRIPTION OF RESPONDENTS: Potential respondents include all WTC EHC members who present for a visit at any of the three WTC EHC sites. Clinical visits include initial screening, annual monitoring, treatment and diagnostic visits. During a typical calendar year, approximately 5,000 unique members may present for a clinical visit. Respondents will include both new members and those who have received previous healthcare services from the WTC EHC.

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: _____Emily Hurwitz ___________________________

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

Personally Identifiable Information:

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

During the visit registration/check‐in process, members will be given a one‐page consent form describing the survey and requesting consent to participate. Members will select if they would like to receive the survey via mobile telephone text message, email or MyChart portal link. The front desk staff will scan and upload completed (signed) consent forms to a designated folder on a secured network drive maintained by the H+H WTC EHC. The Data Center will maintain a record of members informed of and acknowledging the survey (both consenting and declining consent).

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

3. If Applicable, has a System or Records Notice 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	No. of Responses per Respondent	Participation Time	Burden
Individuals	5000	1	5/60	417
Totals				417

FEDERAL COST: The estimated annual cost to the Federal government is _­$2500 ____

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?

Convenience sampling will be used to identify respondents. All WTC EHC members who present for a clinic visit will be asked to participate in the survey. Survey administration will be conducted on a rolling basis.

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

SurveyMonkey, a web-based software package with HIPAA-compliant administrative functions, will be used to conduct the survey. During the visit registration/check in process, members will be given a one-page consent form describing the survey and requesting consent to be contacted for participation. Members can elect to receive the survey link via text, email, or through the patient portal of their electronic medical record (NYC Health + Hospitals uses EPIC MyChart). Members can also decline consent. Consenting members will be sent the survey link after completing their clinic visit. Consenting members who have not completed the survey, will be sent direct reminders every 2‐3 weeks through SurveyMonkey. After a total of three contact attempts have been made, members who have not responded shall be removed from the outreach contact list.

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.

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.

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.

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

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