One Page Justification

Request for Approval under the “Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery” (OMB Control Number: 0704-0553)

TITLE OF INFORMATION COLLECTION: MHS Facilities Design Survey

PURPOSE: The Military Health System (MHS) Facilities Design Survey is a survey deployed to beneficiaries who had an inpatient hospital stay in the past year and their spouses. The purpose of the survey is to help the Defense Health Agency (DHA) understand Active Duty Service Members (ADSMs) and their spouses’ perspectives and gain patient feedback on which features they would most like to see integrated into new or refurbished facilities (hospitals).

DESCRIPTION OF RESPONDENTS: Respondents are beneficiaries (patients) who had an inpatient hospital stay at a military medical treatment facility (MTF). The majority of respondents will be the ADSM with the spouse being an additional option to also complete the survey.

For the purposes of this public information collection request, only the spouse respondents are accounted for in the burden estimates below. Please note that the survey instrument included in this request shows the telephone script and questions once the phone has been passed to the responding spouse.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [X] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [ ] Other: ______________________

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

3. The collection is non-controversial and does not raise issues of concern to other federal agencies.

4. The results are not intended to be disseminated to the public.

5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

6. The 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 future.

Name: Dr Kimberley Aiyelawo, Chief, DHA Patient Experience Measurement, Analytics and Evaluation Division, DHA

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [X] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [X] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals or Households (Active Duty Service Member Spouses)	55	5 minutes	4.58 hours
Totals	55		5 hours

PUBLIC COST: The estimated annual cost to the public is _$176___________

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [X] Yes [ ] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

The sampling process will involve extracting a random list of 15,000 beneficiaries who have recently (within the past 12 months) been inpatient recipients of care at an MTF. From this list of eligible participants, a random sample of 1,500 ADSM respondents will be selected to complete the survey. Once an ADSM has completed their response, they will be asked if they are married. If they say yes, the interviewer will ask if the spouse is available and willing to be surveyed as well.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[X] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [X] Yes [ ] No

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