Generic Clearance Submission Template

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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0648 Exp Date: 05/2021)

TITLE OF INFORMATION COLLECTION:  Patient Perception Surveys – Behavioral Health (CC)

PURPOSE:  The purpose of this survey is to solicit feedback on the patient experience at the National Institutes of Health Clinical Center (NIHCC).  We have ensured that these survey activities, which are designed to gather and measure customers’ perceptions of the quality of the Clinical Center’s services and operations, satisfy the requirements and the spirit of Executive Order (EO) 12862.  Furthermore, periodic surveys of patient perceptions of their care is a requirement for hospital accreditation by The Joint Commission, (American Nurses Credentialing Center (ANCC), and other accrediting organizations.  Our planned activities for the next several years reflect our ongoing emphasis on performance improvement activities, and our reliance on the valuable data generated from these surveys.  

DESCRIPTION OF RESPONDENTS: The sample will consist of adult and pediatric in- and outpatients admitted to the NIH Clinical Center for participation in behavioral health-related clinical research.

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:  Natascha Pointer

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

Personally Identifiable Information:
    1. Is personally identifiable information (PII) collected?  [x] Yes  [ ]  No 
    2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974?   [x] Yes [  ] No   
    3. If Applicable, has a System or Records Notice been published?  [x] Yes  [  ] No

Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?  [  ] Yes [x] No  

ESTIMATED BURDEN HOURS and COSTS

Form
Category of Respondent 
No. of Respondents
No. of Responses per Respondent
Time per
Response
(in hours)
Total Burden
Hours
Adult Inpatient Behavioral Health Survey
Individual / Household
75
4
5/60
25
Pediatric Inpatient Behavioral Health Survey
Individual / Household
25
4
5/60
8
Adult Outpatient Behavioral Health Survey
Individual / Household
125
4
5/60
42
Pediatric Outpatient Behavioral Health Survey
Individual / Household
75
4
5/60
25

Totals
300
1200

100


 Category of Respondent

Total Burden
Hours
Hourly Wage Rate*
Total Burden Cost
Individual / Household
101
$11.75
$1,187




Totals
101

$1,187
*Hourly Wage Rate is minimum wage for Maryland: http://www.ncsl.org/research/labor-and-employment/state-minimum-wage-chart.aspx ($11.75 effective 1/1/21)


FEDERAL COST:  The estimated annual cost to the Federal government is $13,909
                         

 Staff

Grade/Step
Salary
% of Effort
Fringe (if applicable)
Total Cost to Gov’t
Federal Oversight





Program Specialist
12/7
$104,641
1%

$1,047






Contractor Cost




$12,862






Travel





Other Cost











Total




$13,909



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?

Adult patients and the primary care givers of all pediatric patients, admitted to or visiting the NIH Clinical Center (NIHCC), are invited to participate in a patient perception survey following their visit. Survey version will vary depending on services received. 

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

In keeping with the standardized survey methodology developed by the survey contractor, an industry leader, the adult patients and primary care givers of NIH Clinical Center (NIHCC) pediatric inpatients participating in behavioral health research will be handed the survey with a business reply envelope to be mailed to the contractor; again, this is the industry standard. Their responses are returned to a third-party contractor, and de-identified results are made available to the NIHCC through a secure, web-based portal.

    2. Will interviewers or facilitators be used?  [  ] Yes [x] No
 
Please make sure that all instruments, instructions, and scripts are submitted with the request.