After Visit Summary 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:

After Visit Summary Survey

PURPOSE OF COLLECTION:
The purpose of this survey is to evaluate user satisfaction with
the After Visit Summary (AVS). An AVS gives VA patients a
summary of their clinic visit; only patients who have registered
would have access to the AVS. The AVS contains specific
information and provides a summary of patient health information
that can be used to review a medical record and to share
essential information with health care providers.
This survey is designed to obtain critical information for VA
that will assist in determining health and information
knowledge. The data that is gathered aligns with the
department's core mission of improving the health and welfare of
veterans. Historically, recipients of VA surveys have
participated at historically high response rates, because the
data is used to effect significant improvements in veteran's s
health programs. The survey will Collect metrics related to the
pillar of “trust” as an overall customer experience metric on
VA.gov and MyHealtheVet desktop.
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
[ ] 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

1

3. Who will you collect the information from?
Users who interact with the MyHealtheVet system or Oracle Health
web pages. All results are voluntary and anonymous. Only users
with accounts will be surveyed as login is necessary to view
these pages or desktop version.
4. How will you ask a respondent to provide this information?
A user feedback button will be available on each of the web
pages and related to the systems for response. A pop-up survey
will be supplied to 50% of users who remain on the page for one
minute. All responses are anonymous and do not collect PII
information.
5. What will the activity look like?
A user feedback button will be available on each of the web
pages and related to the systems for response. A pop-up survey
will be supplied to 50% of users who remain on the page for one
minute. All responses are anonymous and do not collect PII
information.
6. Please provide your question list.
Please see attached.
7. When will the activity happen?
This survey will remain on our website in alignment with the
timing of the overall clearance.
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
Individuals and Households

No. of
Respondents
50,000/year

Participation
Time
3

Burden
Hours
2500

Totals

50,000/year

3

2500

CERTIFICATION:

2

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: 2/28/2026

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