Patient Survey Crownpoint Template

Request for Approval under the “Generic Clearance for the Collection of
Qualitative Feedback on Agency Service Delivery”
(OMB Control Number: 0917-0036)
TITLE OF INFORMATION COLLECTION:
Patient Satisfaction Survey
Crownpoint Service Unit – Indian Health Services
PURPOSE:
For Crownpoint Service Unit to collect information for patient’s perception of care as needed for
Centers for Medicare and Medicaid Services and Joint Commission Accreditation and for the
Service Unit’s ongoing performance improvement for quality and safe patient care.
DESCRIPTION OF RESPONDENTS:
The respondents would be the patients and visitors of Crownpoint Service Unit, includes two (2)
satellite clinics at Pueblo Pintado Health Clinic and Thoreau Health Service.
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: web-surveys

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: ____Laberta Farrell, Director, Division of Quality Management___________
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 N/A

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3. 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

No. of
Participation
Respondents Time

Patients and visitors

0-500

10 minutes

Annual
Burden
Hrs.
83

Totals
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:
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)
[ ] Web-based or other forms of Social Media
[ ] Telephone
[ ] In-person
[ ] Mail
[ X ] Other, Explain Paper, collection via locked boxes or in-person
2. Will interviewers or facilitators be used? [ ] Yes [ X ] No

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Please ensure 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 a statement to that effect in your
explanation. Please include how the information will be used to improve services or the program.
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. Provide the name
of the individual who is the lead contact and responsible for the collection.
Personally Identifiable Information: Provide answers to the questions. Note:
Agencies/Programs 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. If you request PII,
please ensure that you state the reason why it is being collected (i.e., in order to respond to
inquiries from the participants).
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 (minutes).
FEDERAL COST: Provide an estimate of the annual cost (and description) to the Federal
Government. Please provide a brief break down of the costs, including wages for staff utilizing
OPM pay scale table. See https://www.opm.gov/policy-data-oversight/pay-leave/salarieswages/salary-tables/pdf/2015/GS_h.pdf
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
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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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