Epilepsy Centers of Excellence (ECoE) Satisfaction Survey

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

TITLE OF INFORMATION COLLECTION:

VA Epilepsy Center of Excellence (ECoE) Outpatient Clinic Patient Satisfaction Survey

PURPOSE:

The VA Epilepsy Center of Excellence (ECoE) will conduct a standardized patient satisfaction survey questionnaire across 16 sites to collect voluntary patient feedback after neuro-epilepsy new and follow up outpatient clinic visits. The survey, which will ask patients to go onto surverymonkey.com and answer nine questions, will ultimately yield the purpose of soliciting feedback and collecting information from patients. The information collected will be utilized internally by ECoE to formulate recommendations for the development of epilepsy services and improve quality of care provided to veterans in epilepsy clinic based on patients’ response. No patient identifiable information will be asked, collected, or stored. Patient responses will be utilized internally within the ECoE, not shared publically, and not utilized for research purposes.

DESCRIPTION OF RESPONDENTS:

Respondents of the survey will consist of Veteran patients with epilepsy and seizure, who are seen in the neuro-epilepsy new and follow up outpatient clinics, throughout 16 ECoE sites, located at San Francisco, Los Angeles, Albuquerque, San Antonio, Durham, Tampa, Gainesville, Miami, Richmond, Baltimore, West Haven, Seattle, Portland, Minneapolis, and Madison VA Medical Centers.

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:

Ryan Rieger, ECoE National Administrative Director

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 Individuals or Households	No. of Respondents	Participation Time	Burden
VA Form 10-0558	1,740	10 minutes	290 hrs
Totals	1,740	10 minutes	290 hrs

FEDERAL COST: The estimated annual cost to the Federal government is $0

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?

Each of the 16 ECoE sites is responsible for managing their patient list of Veterans patients with epilepsy and seizure, who are seen in the neuro-epilepsy new and follow up outpatient clinics. All patients seen in neuro-epilepsy new and follow up outpatient clinics at the 16 ECoE sites will be asked to complete survey, no sampling will be done. In FY11, the total volume of patients seen in neuro-epilepsy new clinics was 2,168 encounters and in neuro-epilepsy follow up 6,532 encounters across all 16 ECoE sites. Of the total 8,700 encounters, we estimate a patient satisfaction survey response rate of 20%, totaling 1,740 respondents.

Administration of the Instrument

1. 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

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

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