MOVE! Maintenance Pilot Program 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:
MOVE! Maintenance Pilot Program Survey
PURPOSE OF COLLECTION:
The VA MOVE! Weight Management Program intends to ensure the
quality of customer service and satisfaction provided to Veterans
aligns with the VA Secretary’s priority. The survey will provide
information from Veterans about their experience and satisfaction
with the MOVE! Maintenance Pilot Program. The survey will be
instrumental to the VA MOVE! Weight Management Program in their
efforts to improve the quality of service delivery and to help
shape the direction and focus of MOVE! and the Veteran experience.
The information will also be used to evaluate how well facilitybased MOVE! programs are meeting Veteran and program goals.
In order to capture the voice of the Veterans who have participated
in the MOVE! Maintenance Pilot Program, the Veteran Experience
Office (VEO) will leverage VSignals to collect feedback through a
short, low burden customer experience survey delivered as a URL and
QR code for distribution. The survey is completed via a web-based
survey design and contains questions to identify customer
satisfaction and customer service areas that may need improvement.
The survey will in no way collect nor share personally identifiable
information. The participant can choose to exit the survey at any
time before submitting their survey response.
A new question is being added for Veterans
facility. Veterans will be asked to answer
specific location for completing the MOVE!
better evaluate the service points for the

to identify the specific
the question of the
Maintenance program to
program.

TYPE OF ACTIVITY: (Check one)
[ ] Customer Research (Interview, Focus Groups, Surveys)
[ x] Customer Feedback Survey
[
] Usability Testing of Products or Services
ACTIVITY DETAILS
1. If this is a survey, will the results of this survey be
reported to Touchpoints as part of quarterly reporting
obligations specified in OMB Circular A-11 Section 280?
[ ] Yes

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[ x ] No
[ ] Not a survey
2. How will you collect the information? (Check all that apply)
[x ] Web-based or other forms of Social Media
[ ] Telephone
[ ] In-person
[ ] Mail
[ ] Other, Explain
3. Who will you collect the information from?
The survey will be offered to all Veterans who have participated in
the MOVE! Maintenance Pilot Program. There will be the following
statement asking the participants to take the survey:
“We want to hear about your experience with the MOVE! Maintenance

sessions. By responding to this survey, you will directly help us
improve the program, and provide better support to Veterans like
you.”
Participants will choose whether they want to click on the link and
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.

4. How will you ask a respondent to provide this information?
In order to capture the voice of the Veterans who have participated
in the MOVE! Maintenance Pilot Program, the Veteran Experience
Office (VEO) will leverage VSignals to collect feedback through a
short, low burden customer experience survey delivered as a URL and
QR code for distribution. The survey is completed via a web-based
survey design and contains questions to identify customer
satisfaction and customer service areas that may need improvement.
The survey will in no way collect nor share personally identifiable
information. The participant can choose to exit the survey at any
time before submitting their survey response.
5. What will the activity look like?
In order to capture the voice of the Veterans who have participated
in the MOVE! Maintenance Pilot Program, the Veteran Experience
Office (VEO) will leverage VSignals to collect feedback through a
short, low burden customer experience survey delivered as a URL and
QR code for distribution. The survey is completed via a web-based
survey design and contains questions to identify customer
satisfaction and customer service areas that may need improvement.
The survey will in no way collect nor share personally identifiable
information. The participant can choose to exit the survey at any
time before submitting their survey response.

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The burden time is 3 minutes for completion.
6. Please provide your question list.
See Attached.
7. When will the activity happen?
The survey will be offered to all Veterans who have participated in
the MOVE! Maintenance Pilot Program upon completion.

8. Is an incentive (e.g., money or reimbursement of expenses,
token of appreciation) provided to participants?
[ ] Yes [x ] No
If Yes, describe:
XXX
BURDEN HOURS
Category of Respondent

No. of
Respondents

Participation
Time

Burden
Hours

Individuals

200

3 minutes

10 hours
10 hours

Totals

200

3 minutes

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;
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
7. Upon agreement between OMB and the agency aggregated data may
be released as part of A-11, Section 280 requirements only on
performance.gov. Summaries of customer research and user
testing activities may be included in public-facing customer
journey maps.
8. Additional release of data will be coordinated with OMB.

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Name and email address of person who developed this survey/focus
group/interview:
Name: ___Brian Brown_________
Email address: [email protected]__________
All instruments used to collect information must include:
OMB Control No. XXXX-XXXX
Expiration Date: XX/XX/XXXX

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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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