Information Collection Request

Request for Approval under the “Generic Clearance for Improving Customer
Experience (OMB Circular A-11, Section 280 Implementation)” (OMB Control
Number: 2900-0876)
TITLE OF INFORMATION COLLECTION: Telehealth ATLAS Survey
PURPOSE
Telehealth ATLAS (Advancing Telehealth through Local Access Stations) will collect feedback
through a short, low burden customer experience survey. The purpose of the survey is to understand the
experience of veterans that have a Telehealth visit at the ATLAS pilot site.
The survey will be delivered by displaying a link, unique for each ATLAS site, to the survey
immediately following the ATLAS appointment, using the computer on which the Telehealth ATLAS
appointment is conducted.
The survey is completed via a web-based survey design and contains general Likert-scale (a scale of
1-5 from Strongly Disagree to Strongly Agree) questions, checkbox and radio button questions, to assess
customer experience. Participants will choose whether they want to click on the link, or whether they want
to participate after opening the survey. The participant can choose to exit the survey at any time before
submitting their survey response.

DESCRIPTION OF RESPONDENTS:
The survey will be offered to veterans and their families who are interested in having a telehealth
appointment but want to avoid long travel times to the nearest VA facility or have challenges with telehealth
appointments due to internet connectivity at home.

TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[X] Customer Satisfaction Survey
[ ] Small Discussion 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. Personally identifiable information (PII) is collected only to the extent necessary and is not retained.
5. Information gathered is intended to be used for general service improvement and program management
purposes.
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.
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7. All or a subset of information may be released as part of A-11, Section 280 requirements on
performance.gov. Additionally, summaries of the data may be released to the public in communications
to Congress, the media and other releases disseminated by VEO, consistent with the Information Quality
Act.
Name: Evan Albert, Dir. of Measurement and Data Analytics, Veterans Experience Office, VA, (202) 8759478

To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Will this survey use individualized links, through which VA can identify particular respondents even if
they do not provide their name or other personally identifiable information on the survey? [ ] Yes [X]
No
2. Is personally identifiable information (PII) collected? [ ] Yes [X] No
3. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of
1974? [ ] Yes [ ] No [N/A]
4. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No [N/A]
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
Individuals and Households
Totals

No. of
Respondents
200 Annually
200 Annually

Participation
Time
5 minutes
5 minutes

Burden
17 hours
17 hours

*Q4

Please answer the following questions.
1. Are you conducting a focus group, a survey that does not employ random sampling, user testing
or any data collection method that does not employ statistical methods?
Yes _ X __
No _ _

If Yes, please answer questions 1a-1c, 2 and 3.
If No, please answer or attach supporting documentation that answers questions 2-8.
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a. Please provide a description of how you plan to identify your potential group of respondents and
how you will select them.
•

The survey will be offered to veterans and their families who are interested in having a telehealth
appointment but want to avoid long travel times to the nearest VA facility or have challenges
with telehealth appointments due to internet connectivity at home. The survey will be delivered
by displaying a link, unique for each ATLAS site, to the survey immediately following the
ATLAS appointment, using the computer on which the Telehealth ATLAS appointment is
conducted.

b. How will you collect the information? (Check all that apply)
[X] Web-based or other forms of Social Media
[ ] Telephone
[ ] In-person
[ ] Mail
[ ] Other- E-mail-based surveys
c. Will interviewers or facilitators be used? [ ] Yes [ X ] No
2. Please provide an estimated annual cost to the Federal government to conduct this data collection:
__$13,000______
3. Please make sure that all instruments, instructions, and scripts are submitted with the request. This
includes questionnaires, interviewer manuals (if using interviewers or facilitators), all response options
for questions that require respondents to select a response from a group of options, invitations given to
potential respondents, instructions for completing the data collection or additional follow-up requests for
the data collection.
•

Done

4. Describe (including a numerical estimate) the potential respondent universe and any sampling or other
respondent selection methods to be used. Data on the number of entities (e.g., establishments, State and
local government units, households, or persons) in the universe covered by the collection and in the
corresponding sample are to be provided in tabular form for the universe as a whole and for each of the
strata in the proposed sample. Indicate expected response rates for the collection as a whole. If the
collection had been conducted previously, include the actual response rate achieved during the last
collection.
•

Not applicable

5. Describe the procedures for the collection of information, including:
a. Statistical methodology for stratification and sample selection.
b. Estimation procedure.
c. Degree of accuracy needed for the purpose described in the justification.
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d. Unusual problems requiring specialized sampling procedures.
e. Any use of periodic (less frequent than annual) data collection cycles to reduce burden.
•

Not applicable.

6. Describe methods to maximize response rates and to deal with issues of nonresponse. The accuracy and
reliability of information collected must be shown to be adequate for intended uses. For collections
based on sampling, a special justification must be provided for any collection that will not yield
"reliable" data that can be generalized to the universe studied.
•

Not applicable.

7. Describe any tests of procedures or methods to be undertaken. Testing is encouraged as an effective
means of refining collections of information to minimize burden and improve utility. Tests must be
approved if they call for answers to identical questions from 10 or more respondents. A proposed test or
set of tests may be submitted for approval separately or in combination with the main collection of
information.
•

Not applicable.

8. Provide the name and telephone number of individuals consulted on statistical aspects of the design and
the name of the agency unit, contractors, grantees, or other person(s) who will actually collect or
analyze the information for the agency.
•
•
•

Evan Albert, Dir. of Measurement and Data Analytics, Veterans Experience Office, VA, (202)
875-9478
Dan Ostrow, VSignals Implementation Lead, Veterans Experience Office, VA, (414) 690-8587
Lesly Roose, ATLAS Program Manager, Office of Connected Care, Telehealth, (814) 932-0536

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