ICR Template Section 280 VHA ALS

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: VHA ALS Customer Experience Survey

PURPOSE OF COLLECTION:

What are you hoping to learn / improve? How do you plan to use what you learn? Are there artifacts (user personas, journey maps, digital roadmaps, summary of customer insights to inform service improvements, performance dashboards) the data from this collection will feed?

There are approximately 4,000 Veterans who are being treated for ALS in the Veterans Health Administration system. Veterans are twice as likely to die from ALS when compared to their civilian counterparts. Department of Veterans Affairs would like to conduct a survey with Veterans receiving benefits because of their ALS diagnosis to ensure access to high quality ALS care throughout the enterprise and identify Veteran priorities as it relates to their ALS care. The data from the survey will be used for continuous quality improvement.

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

3. Who will you collect the information from?

Explain who will be interviewed and why the group is appropriate for the Federal program / service to connect with. Please provide a description of how you plan to identify your potential group of respondents and if only a sample will be solicited for feedback, how you will select them(e.g., anyone who provided an email address to a call center rep, a representative sample of Veterans who received outpatient services in May 2019, do you have a list of customers to reach out to (e.g., a CRM database that has the contact information, intercept interviews at a particular field office?)

The population consists of Veterans and caregivers who are receiving healthcare or disability compensation benefits based on their ALS diagnosis. The population will be pulled from a current VA database that keeps tracks of Veterans with an ALS diagnosis in their VA medical records and any Veteran with an approved disability compensation claim for ALS. Given that the population is relatively small all Veterans in the database with a valid email address who have not previously opted out from receiving VSignals surveys will be sent the voluntary survey.

4. How will you ask a respondent to provide this information?

(e.g., after an application is submitted online, the final screen will present the opportunity to provide feedback by presenting a link to a feedback form / an actual feedback form)

The URL to the survey will be sent via email. Participants will choose whether they want to click on the link, or whether they want to participate after opening the survey

5. What will the activity look like?

Describe the information collection activity – e.g. what happens when a person agrees to participate? Will facilitators or interviewers be used? What’s the format of the interview/focus group? If a survey, describe the overall survey layout/length/other details? If User Testing, what actions will you observe / how will you have respondents interact with a product you need feedback on?

The activity will be an electronic survey that takes approximately five minutes to complete.

6. Please provide your question list.

Please see attached documents for correct formatting. Some formatting may have been lost due to issues with copy/pasting into this writeup. Additionally, “Required” and “Logic” statements are for explaining survey logic and will not appear on the actual survey.

TITLE: VHA ALS Customer Experience Survey

We want to hear about your experiences with your treatment for ALS. By responding to this survey, you will directly help us improve the quality of care the VA provides Veterans with ALS.

This voluntary survey should take approximately 5 minutes to complete.

1. Where do you receive your ALS Care? (Select only one option) Required

   1. VA

   2. Community Provider

   3. Both

2. Which of the following ALS symptoms do you have and are being treated for? (Select all that apply) <question is a table format that has separate columns for both “I have these Symptom(s)” and “I have received treatment for these Symptom(s)” see attached>

   1. Muscle Weakness

   2. Muscle Cramps

   3. Twitching

   4. Stiff Muscles

   5. Speech Challenges

   6. Trouble Swallowing

   7. Drooling

   8. Involuntary Emotional Expressions

   9. Fatigue

   10. Trouble breathing or shortness of breath

   11. Insomnia

   12. Constipation

   13. Urinary Difficulty

   14. Stomach pain, nausea, bloating, or fullness

   15. Pain

3. <Logic only display if Veteran selects Community Provider or both> Why might you choose to get treated for ALS at a community medical facility as opposed to VA? (Select all that apply)

   1. I am treated with courtesy and respect

   2. I don’t trust VA in general

   3. I am familiar with the community medical facility

   4. I trust the community medical facility to provide comprehensive ALS treatment

   5. I have more options for appointment dates/times

   6. The process of scheduling appointments is easier

   7. Close to my home/easy to get to

   8. Continuity of care from provider who initially diagnosed me

   9. I am not familiar with the VA healthcare benefits (e.g. equipment, medication management) that I’m entitled to for my ALS care

4. I have experienced barriers in accessing the following related to my ALS care. (Select all that apply)

   1. Scheduling a VA clinical appointment

   2. Medications/Prescriptions

   3. Equipment

   4. Specialty referrals

   5. Home Care Services

   6. Support for my Caregiver

   7. Mental Health Support

   8. Transportation

   9. Lodging

   10. Telehealth care

   11. Delay in receiving Disability Compensation Benefits

   12. N/ A have not encountered any barriers

5. My ALS care team and/or Veteran Service Officer (VSO) provided me with information regarding the following (Select all that apply)

   1. Research Opportunities

   2. Home Modifications

   3. Equipment

   4. Vehicle Grant

   5. Monthly VA Disability Compensation payments

   6. Caregiver Support

   7. Planning for Future Care Needs

   8. Genetic Testing

   9. N/A

6. What would you like prioritized most related to your ALS care? (Rank all that apply)

   1. Symptom Management

   2. Access to Assistive Devices

   3. Quality of Life Support

   4. Coordination of Care

   5. Access to Clinical Trials and Research

   6. Home Care Services

   7. Support for my Caregiver

   8. Mental Health Support

   9. Information about VA benefits that I am entitled to for ALS (i.e. Equipment, medication management, disability compensation, special adaptive housing grants)

7. I know where to access information about VA ALS care and benefits online.

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

8. <Logic Only display if in VA Care or both> My VA ALS care is coordinated (e.g. appointments, medications, equipment and specialty referrals).

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

9. <Logic Only display if Community Provider> My ALS care is coordinated. (e.g. appointments, medications, equipment and specialty referrals).

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

10. <Logic Only display if in VA Care or both> I receive ALS support from my ALS care team in a reasonable amount of time.

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

11. My personal preferences (i.e. cultural and/or spiritual) are considered during my ALS treatment to address my needs.

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

12. My ALS Care team communicates in a way that I understand.

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

13. My ALS care team takes time to understand my goals and preferences and assist in documenting in Advance Care Directive.

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

14. <Logic Only display if in VA Care or both> I am satisfied with the care I receive from the VA for ALS.

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

15. I trust VA ALS Care team to fulfill its commitment to Veterans, families, caregivers, and survivors. Required

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

Please make sure that all instruments, instructions, and scripts are submitted with the request.

Done

7. When will the activity happen?

Describe the time frame or number of events that will occur (e.g., We will conduct focus groups on May 13,14,15, We plan to conduct customer intercept interviews over the course of the Summer at the field offices identified in response to #2 based on scheduling logistics concluding by Sept. 10^th, or “This survey will remain on our website in alignment with the timing of the overall clearance.”)

The survey will be sent mid-January

8. 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	Participation Time	Burden Hours
Individuals	1,000	5 minutes	83.3 hours
Totals	1,000	5 minutes	83.3 hours

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: ____Todd Stawicki________________

Email address: _[email protected]__________

All instruments used to collect information must include:

OMB Control No. 2900-0876

Expiration Date: 02/28/2026

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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