Clinical Screening Tool Survey

Request for Approval under the “Generic Clearance for Improving
Customer Experience: OMB Circular A-11, Section 280
Implementation”
(OMB Control Number: )
TITLE OF INFORMATION COLLECTION:

Clinical Screening Tool Survey

PURPOSE OF COLLECTION:
Clinical reminders assist clinical decision-making and improve
documentation and follow-up, by allowing providers to track and
document when care has been delivered. This can assist providers
in performing evaluations to enhance the quality of Veteran
healthcare. However, the volume of clinical reminders has
impacted the quality of the patient-provider encounter and
increased cognitive burden on clinical teams. Therefore, the
Veteran Health Administration (VHA) is in search of an
enterprise tool which enables customizable and standardized
questionnaires to be sent to the patient to collect responses
asynchronously.
The VHA Office of Connected Care (OCC) in partnership with
Office of the Chief Technology Officer (OCTO) is conducting a
pilot of two digital questionnaire tools within the VA
ecosystem, Behavioral Health Labs (BHL) and eScreening. The
pilot will allow OCC and OCTO to gather more insight about these
tools.
The goal of this survey is to understand the Veteran’s
experience in completing questionnaires during the BHL and
eScreening pilot. Research goals include:
• understanding if Veterans prefer the digital experience or
in-person experience with a provider
• Veterans were satisfied with their experience
• Veterans understand what was being asked of them throughout
the questionnaires
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
[ X ] No

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[

] 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 VHA Office of Connected Care (OCC) in partnership with
Office of the Chief Technology Officer (OCTO) is conducting a
pilot of two digital questionnaire tools within the VA
ecosystem, Behavioral Health Labs (BHL) and eScreening. A link
to the VSignals survey will be provided immediately at the end
of every BHL and eScreening experience for this pilot, which
Veterans can opt into and provide feedback.
4. How will you ask a respondent to provide this information?
A link to the VSignals survey will be accessible through a
paper link and QR code at the end of every BHL and eScreening
experience for this pilot, which Veterans can opt into and
provide feedback from their own device. The survey results
will be used to evaluate the research goals. Surveys will be
anonymous.
5. What will the activity look like?
The survey will be offered to the attendee by VA staff through a
provided link or QR code as a paper handout. The attendee can
fill out the survey immediately on their own device or at their
convenience. The attendee can choose to use a personal device
through a url link or QR code provided. 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 at a later
date.
6. Please provide your question list.
See Attached
7. When will the activity happen?
This will be ongoing at the completion of one of the screening
tools at one of the VISN locations. This should last
approximately six months, or up to 500 results per screening
tool. Whichever occurs first.
8. Is an incentive (e.g., money or reimbursement of expenses,
token of appreciation) provided to participants?

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[ ] Yes [ X ] No
If Yes, describe:
XXX
BURDEN HOURS
Category of Respondent

No. of
Respondents
1000

Individuals and households

Participation
Time
3 minutes

Burden
Hours
50
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;
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.
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. 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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