A-11 Fast-Track Clearance Request Template PACT Act Outreach Survey

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: Promise to Address Comprehensive
Toxics (PACT) Act Outreach survey
PURPOSE
The PACT Act is a new law that expands VA health care and benefits for Veterans
exposed to burn pits, Agent Orange, and other toxic substances. The PACT Act adds to
the list of health conditions that we assume (or “presume”) are caused by exposure to
these substances. This law helps provide generations of Veterans—and their survivors—
with the care and benefits they’ve earned and deserve. The purpose of this survey is
measure Veteran experience when learning about benefits before filing a claim and glean
insights with the objective of improving outreach and overall outcomes for Veterans.

DESCRIPTION OF RESPONDENTS:
Veterans who have attended a Promise to Address Comprehensive Toxics (PACT) Act
outreach event or have searched for information regarding PACT Act benefits. will have
the ability to scan a QR code to take the survey.
The survey will also be offered through the VetResources newsletter email that goes out to
veterans enrolled in VA benefits programs. Participants will choose whether they want to click
on the link, or whether they want to participate after opening the survey.

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.

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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.
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: Sergio Gazaryan, Enterprise Measurement Project Manager, Veterans Experience
Office, VA (603) 203-3167

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

No. of
Respondents
100,000
100,000

Individuals and Households
Totals

Participation
Time
5 minutes
5 minutes

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?

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Burden
8,333 hours
8,333 hours

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.
a. Please provide a description of how you plan to identify your potential group
of respondents and how you will select them.
The population consists of Veterans who attended a PACT Act outreach event or
searched for information regarding PACT Act benefits.
b. How will you collect the information? (Check all that apply)
[ x] Web-based or other forms of Social Media
[ ] Telephone
[ x ] In-person
[ ] Mail
[X] 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.
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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.
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.
•

Collection and Analysis:
o Evan Albert, Dir. of Measurement and Data Analytics, Veterans
Experience Office, VA (202) 875-9478
o Dan Ostrow, Portfolio Manager, Veterans Experience Office, VA
(414) 690-8587

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