Generic Request Surgical Patient Satisfaction Survey 1-2014

Request for Approval under the "Generic Clearance for the Collection of Routine Customer Feedback" (OMB Control Number: 2900-0770)

TITLE OF INFORMATION COLLECTION:

Surgical Patient Satisfaction Survey

PURPOSE: These surveys are used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this survey will lead to improvements in the quality of service delivery by helping to shape the direction and focus of specific programs and services.

DESCRIPTION OF RESPONDENTS: The survey participants are patients that are undergoing the process of surgery. This will measure the service provided at the clinic until discharge after the procedure. The survey participants would include outpatients or persons requiring hospital admittance.

TYPE OF COLLECTION: (Check one) [ ] Customer Comment Card/Complaint Form [ ] Usability Testing (e.g., Website or Software [ ] Focus Group	[x] Customer Satisfaction Survey [ ] Small Discussion Group [ ] Other:

CERTIFICATION:

I certify the following to be true:

• The collection is voluntary.

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

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

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

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

• 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: Axel Roman, Chief, Patient and Community Relations  

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

Personally Identifiable Information:

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

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

If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [X] 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: Individuals and Households	No. of Respondents	Participation Time	Burden
VA Form 10-211015 (English) (& Spanish-10-211015SP)	5 /per day	20 minutes	608
Totals			608 hrs

FEDERAL COST: The estimated annual cost to the Federal government is $800.00

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

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?

VA will recruit at least 5 voluntary patients per day, upon clinical discharge following the surgical procedure. (See sample of “Daily Schedule of Surgery”).

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[x] Other, Explain: VA will recruit voluntary outpatients upon clinical discharge or persons requiring hospital admittance.

Will interviewers or facilitators be used? [ ] Yes [ x] No

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