ICR A-11 Section 280 BTSSS Change Request Cover Sheet

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: Beneficiary Travel Self Service System (BTSSS) Survey

PURPOSE OF COLLECTION:

VHA's Veterans Transportation Program (VTP) has implemented a new modality for Veterans to submit their Beneficiary Travel reimbursement applications called the Beneficiary Travel Self Service System (BTSSS). BTSSS Offers veterans and Caregivers web-based tool that can be used 24/7/365, accessible from anywhere with an internet connection, and allows them to track their claim status at any time. The intent for implementing BTSSS is two-fold: 1) provide Veterans a more stream-lined reimbursement application process that does not involve visiting a VA Medical Center or sending through the US Postal Service, and 2) improve the Agency's ability process reimbursement applications in an accurately and timely manner.

To capture the voice of the Veteran, the Veteran Experience Office (VEO) will leverage VSignals to collect feedback through a short, low burden customer experience survey. The survey is completed via a web-based survey design and contains questions around veteran’s experience using the BTSSS Veteran Portal to submit their travel reimbursement applications. The participant can choose to exit the survey at any time before submitting their survey response.

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 survey will be offered to a random sample of approximately 20,000 veterans that have used Veteran Transportation Program within the past 30 days monthly in order to reach the target monthly sample of 1,950 Veterans assuming a response rate of 15%. For further details on the sampling methodology that will randomly select the veterans receiving the survey, please see attached sample plan. The survey will be sent via an email invitation. Participants will choose whether they want to click on the link, and whether they want to participate after opening the 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 survey will be sent to eligible veterans after using BTSSS services. Eligible Veterans data are compiled at the end of the month post BTSSS services; and the survey data collection occurs for 2 weeks after the survey is sent out.

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 5 minutes to complete.

6. Please provide your question list.

7. 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: Beneficiary Travel Self Service System (BTSSS)Survey

The Veterans Health Administration (VHA) utilizes the Beneficiary Travel Self Service System (BTSSS) for Veterans to submit their Beneficiary Travel reimbursement applications. The responses you provide will help direct the future of this program so we would greatly appreciate your candid feedback. Thank you for your service.

This voluntary survey should take approximately 5 minutes to complete.

1. How many times per month do you file a claim for beneficiary travel mileage reimbursement?

   1. Less than once a month

   2. 1-2 times per month

   3. 3-5 times per month

   4. More than 5 times per month

2. Which of the following healthcare facilities do you most frequently receive care at? (Select only one option)

   1. VA - VA Medical Center

   2. VA - VA Outpatient Clinic (OPC/CBOC)

   3. Non-VA - Care in the Community

3. What is your comfort level with using a mobile phone, computer, or tablet for filing beneficiary travel reimbursement? (Select only one option)

   1. Uncomfortable

   2. Somewhat comfortable

   3. Very Comfortable

4. Do you need additional training or instruction on how to submit a beneficiary travel claim electronically?

   1. Yes

   2. No

5. Where do you most often go for help with filing beneficiary travel claims? (Select only one option)

   1. My local VA

   2. Online – VA.gov

   3. Beneficiary Travel Self Service System (Help Guide within application)

   4. VA/VSO community events

   5. Other_______________

6. Rank the following in order of importance when filing a beneficiary travel claim. Drag and drop each option to rank.

   1. Ease of submission

   2. Time to get payment (how fast I get paid)

   3. Ability to track my claim status

   4. Ability to file a claim 24/7 (any time I want!)

   5. Other

7. What areas in the Beneficiary Travel Self Service System would you like to see improved? (Select all that apply)

1. Register/Login

2. Claim submission process

3. Mileage expense & mapping calculation tool

4. Adding Attachments

5. Profile update requests (to include updating EFT information)

6. N/A – I have never used the Beneficiary Travel Self Service System

1. It's easy to use the Beneficiary Travel Self Service System <Logic: Will not appear if “What areas in the Beneficiary Travel Self Service System would you like to see improved” is “N/A – I have never used the Beneficiary Travel Self Service System” >

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

9. I'm likely to recommend the Beneficiary Travel Self Service System to a fellow Veteran/beneficiary. <Logic: Will not appear if “What areas in the Beneficiary Travel Self Service System would you like to see improved” is “N/A – I have never used the Beneficiary Travel Self Service System” >

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

10. What is your preferred method to submit a Beneficiary Travel claim? (Select only one option)

    1. I prefer to file a claim online from my own device during check-in for my appointment at the VA facility.

    2. I prefer to file a claim online from my own device – at my convenience – outside the VA facility (e.g. home/residence).

    3. I prefer to file a claim from an on-premises device (e.g. tablet or kiosk like device) at my local VA facility.

    4. I prefer to file a paper claim and submit it to my local VA facility.

11. I trust VA to fulfill our country's commitment to Veterans. Required

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

12. Would you like to provide additional feedback with a compliment, concern or recommendation about your experience(s) with beneficiary travel reimbursement? Please select a response from the following options. Select all that apply. Required

    1. Compliment

    2. Concern

    3. Recommendation

    4. Will not provide additional feedback

13. Compliment <Logic text box only appears if Veteran selects compliment >

Concern <Logic text box only appears if Veteran selects concern >

Recommendation <Logic text box only appears if Veteran selects recommendation >

14. If additional information is needed, can VA contact you about your feedback? Required

    1. Yes, VA can contact me about my experience.

    2. No, I do not want VA to contact me about my experience.

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

Done

8. 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 to eligible veterans after using BTSSS services. Eligible Veterans data are compiled at the end of the month post BTSSS services;

9. 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	156,000	5 minutes	13,000
Totals	156,000	5 minutes	13,000

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: 2/28/2026

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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