Northern Arizona Dental Service 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:
Service survey

Northern Arizona Dental

PURPOSE OF COLLECTION:
Of the 1.4 million Veterans eligible for VA dental care, only
35% are using the benefit.
This underutilization of services
contributes to increased use of emergency care, vulnerability to
tooth decay, and oral disease that can affect overall health. If
VA dental care is underutilized by Veterans, the VA could also
be incurring a higher cost for their care in the community.
Therefore, the Leadership VA (LVA) team wanted to understand the
reasons for the underutilization and to increase participation
in dental services.
TYPE OF ACTIVITY: (Check one)
[ X ] Customer Research (Interview, Focus Groups)
[
] Customer Feedback Survey
[
] User Testing
ACTIVITY DETAILS
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, Email, invitation based
2. Who will you collect the information from?
The LVA will use the VA Northern Arizona Healthcare System as
a sample population. The survey will be offered through
invitation emails that go out to ~1200 dental eligible veterans
in the Northern Arizona area who have not utilized dental
benefits.
3. How will you ask a respondent to provide this information?
The survey will be offered through invitation emails that go out
to ~1200 dental eligible veterans in the Northern Arizona area
who have not utilized dental benefits.

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4. What will the activity look like?
This survey consists of eight questions, offered through
invitation emails that go out to ~1200 dental eligible veterans
in the Northern Arizona area who have not utilized dental
benefits.
5. Please provide your question list.
See attached.
6. When will the activity happen?
This will be a onetime invitation survey with reminders to
complete sent at one week.
7. Is an incentive (e.g., money or reimbursement of expenses,
token of appreciation) provided to participants?
[ ] Yes [ X ] No
If Yes, describe:

BURDEN HOURS
Category of Respondent

No. of
Respondents
1200

Individuals and households

Participation
Time
3 minutes

Burden
Hours
60 hours

Totals

CERTIFICATION:
I certify the following to be true:
1. The collections are voluntary;
2. The collections are low-burden for respondents (based on
considerations of total burden hours or burden-hours per
respondent) and are low-cost for both the respondents and the
Federal Government;
3. The collections are non-controversial and do not raise issues
of concern to other Federal agencies;
4. Any 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 near future;
5. Personally identifiable information (PII) is collected only to
the extent necessary and is not retained;
6. Information gathered is intended to be used for general
service improvement and program management purposes; and,

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7. Information gathered will only be shared publicly in the
manner described in the umbrella clearance of this control
number.
Name: Brian Brown, Enterprise Measurement Project Manager, Veterans Experience Office,
VA 202.664.2924

All instruments used to collect information must include:
OMB Control No. 2900-0876
Expiration Date: 02/28/2026

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HELP SHEET
(OMB Control Number: XXXX-XXXX)
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 this in your explanation.
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.
Personally Identifiable Information: Agencies 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.
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.

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