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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB 0704-0553)

TITLE OF INFORMATION COLLECTION: Military Health System Electronic Health Record End User Survey

PURPOSE:

Anonymous questionnaire will be used to collect feedback from Electronic Health Record (EHR) end users on their thoughts and experiences using the Military Health System’s (MHS).

DESCRIPTION OF RESPONDENTS:

Government, military personnel and contractors assigned to a Military Treatment Facility (MTF). The surveys will be collected over 3 month time period.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [x] Other: User experience questionnaire

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.

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 [ X] No

3. If yes, has an up-to-date System of Records Notice (SORN) 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	Participation Time ( × minutes =)	Burden (÷ 60 =)
Individuals or Households	25,000	10 minutes	4,166
Totals	25,000	10 minutes	4,166

FEDERAL COST: The estimated annual cost to the Federal government is: $0

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

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?

A URL to the customer comment card will be provided to the Defense Health Agency’s (DHA) Office of the Chief Health Informatics Officer (OCHIO). The DHA OCHIO will be asked to distribute the URL, as they deem appropriate, to military, civilian, and contractor personnel within the MHS that utilize the legacy EHR.

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.

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