OMB No. 0917-0036, Mini-Supporting Statement for Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfactio

Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

(OMB Control Number: 0917-0036)

T ITLE OF INFORMATION COLLECTION: OMB No. 0917-0036 Indian Health Service (IHS) Wind River Service Unit (WRSU) Customer Satisfaction Survey

PURPOSE: The IHS goal is to raise the health status of the American Indian and Alaska Native people to the highest possible level by providing comprehensive health care and preventive health services. To support the IHS mission, the Wind River Service Unit (WRSU) is an accredited Medical Home through the Accreditation Association for Ambulatory Health Care (AAAHC), Inc. The attached three patient satisfaction surveys were developed to address the Improving Patient Care Initiative and AAAHC Medical Home standards to health care.

The WRSU through its clinical services department will be responsible for providing oversight for the “Customer Satisfaction Surveys.” The information collected from patients at both the Fort Washakie Health Center and Arapahoe Health Center will be used for quality assurance performance improvements (QAPI) that will result in improved quality of care services.

Voluntary customer satisfaction surveys will be conducted through primarily self-interviews with occasional direct interviews between WRSU staff and patient, phone calls (due to patient complaints), mail, and the internet. The information gathered will be used by agency management and staff to identify strengths and weaknesses in current service provision, to plan and redirect resources, to make improvements that are practical and feasible, and to provide vital feedback at governing body meetings with partner agencies, tribal leaders, system operators, health boards, and community members regarding customer satisfaction or dissatisfaction with WRSU.

DESCRIPTION OF RESPONDENTS: WRSU patients that utilize the Fort Washakie Health Center and the Arapahoe Health Center.

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: Larron Dolence

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 (Minutes per survey)	Burden (Hours per year)
Patient Registration Survey	600	5	50
Patient Wellness Survey	600	5	50
Coordinated Care Survey	600	5	50
Totals	1,800		150

FEDERAL COST: The estimated annual cost to the Federal government is $2,700. At the two (2) federal clinic sites, one staff member will spend 5 minutes per survey performing data collection duties and data analysis. Results will be compiled and analyzed using data system reports that have already been developed. The total 1,800 surveys per year x 5 (minutes) = 9,000 minutes, which is about 150 hours each year, GS 5/6 rate of $18 per hour x 150 is $2,700 per year

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?

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[x] Web-based or other forms of Social Media (Facebook)

[x] Telephone

[x In-person

[x] Mail

[ x] Other, Explain Predominantly self-interviews distributed at key areas in the clinic.

2. Will interviewers or facilitators be used? [ x] Yes [ ] No Occasionally but patients respond better to self-reports.

Interviewers are available as necessary.

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 Qualitative Feedback on Agency Service Delivery”

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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