Anesthesia Patient Satisfaction 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:
Satisfaction Survey

Anesthesia Patient

PURPOSE OF COLLECTION:
The Baltimore VA Medical Center Anesthesia Service has utilized
a validated patient satisfaction survey tool since 2015. This
paper-based survey tool is consistent with our goal of providing
high quality Veteran and family centric care and has guided many
of the perioperative performance improvement initiatives at our
facility over the last eight years. The many hundreds of
provider specific compliments provide important employee
feedback and encouragement. The Anesthesia Service would like to
transition the paper-based survey tool to an electronic format,
compliant with A11 Section 280, so the survey could be completed
on a tablet device. An electronic satisfaction survey tool and
tablet device would be much easier for Veterans and families and
vastly reduce the administrative time and effort required using
a paper format. Review, analysis, and reporting of satisfaction
data would be streamlined using a tablet device.
TYPE OF ACTIVITY: (Check one)
[ ] Customer Research (Interview, Focus Groups)
[ x] Customer Feedback Survey
[ ] User Testing
ACTIVITY DETAILS
1. How will you collect the information? (Check all that apply)
[ x] Web-based or other forms of Social Media
[ ] Telephone
[ ] In-person
[ ] Mail
[ ] Other, Email, invitation based
2. Who will you collect the information from?
• An in-person attempt will be made to collect survey
results from all Veterans (and their families) undergoing
procedures requiring anesthesia support at the Baltimore
VAMC facility. The survey will be filled out by staff on a
tablet by asking the patient the questions of the survey,
or the individual themselves may fill out the survey in
recovery rooms using a provided device or personal device.

1

3. How will you ask a respondent to provide this information?
The survey will be offered to the patient by VA staff through a
provided tablet, filled out by the staff asking the questions
verbally of the patient, or the patient can choose to use a
personal device through a url link or QR code provided bedside
in the recovery room. The url or QR code will be provided on a
sheet of paper for those who prefer to complete the survey
themselves on their own device.
4. What will the activity look like?
The survey will be offered to the patient by VA staff through a
provided tablet, filled out by the staff asking the questions
verbally of the patient, or the patient can choose to use a
personal device through a url link or QR code provided bedside
in recovery. The url or QR code will be provided on a sheet of
paper for those who prefer to complete the survey themselves
on their own device.

5. Please provide your question list.
See attached.
6. When will the activity happen?
This will be ongoing in recovery, post-procedure in the
Baltimore VAMC.
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
2400

Individuals and households

Totals

CERTIFICATION:
I certify the following to be true:

2

Participation
Time
5 minutes

Burden
Hours
200
hours

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,
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

3

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.

4