Supporting Statement

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number:0935-0179)

TITLE OF INFORMATION COLLECTION:

Technical Assistance (TA) User Feedback for Program and User Support and Quality Measure Tool Development for Consumer Assessment of Healthcare Providers and Systems (CAHPS®) and Surveys on Patient Safety Culture^TM (SOPS™) (HHSP233201500026I/HHSP23337004T)

PURPOSE:

In order to assess the effectiveness of the CAHPS and SOPS technical assistance that Westat provides, Westat will ask those that receive technical assistance to complete a brief web-based questionnaire. The feedback will allow Westat to evaluate its performance in meeting user needs and to identify ways to improve its customer service. Westat will ask all users who contact the CAHPS technical assistance mailbox ([email protected]) and the SOPS technical assistance mailbox ([email protected]) to complete a brief web based questionnaire hosted on SurveyMonkey. SurveyMonkey was chosen because it allows for free, easy to use and secure web-based administration. The questionnaire addresses user experience with obtaining timely and useful technical assistance.

DESCRIPTION OF RESPONDENTS:

In order to ensure meaningful feedback, we will ask all users who email CAHPS and SOPS related questions to the CAHPS and SOPS technical assistance mailboxes to complete a brief web-based questionnaire. When responding to technical assistance requests, Westat will include a direct link to the questionnaire at the end of the email response and ask that users complete the questionnaire.

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: Stakeholder Interviews

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:____ Caren Ginsberg____________________________________________

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

3. If Applicable, has a System or Records Notice 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

Category of Respondent: (the options here are Public Sector or Private Sector, or both)

Both

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Web Survey	120	3/60	6 hours
Totals

FEDERAL COST: The estimated annual cost to the Federal government is $356________

Grade	Number of Hours	Value
GS 15-Step 5	2	146
GS 13-Step5	4	210
Total		356

https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/18Tables/html/DCB_h.aspx

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

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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