Patient Satisfaction Svy-Telemedicine/Hem Oncology Services

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

TITLE OF INFORMATION COLLECTION:

Patient Satisfaction Survey -Telemedicine Hem/Oncology Services

PURPOSE:

The Minneapolis HCS Cancer Committee is seeking to collect patient satisfaction information regarding Telehealth services provided in the Hem/Oncology service. The purpose of this patient satisfaction survey is to identify any areas in need of improvement related to Hem/Onc Telemedicine appointments.

DESCRIPTION OF RESPONDENTS:

Eligible patients are any patient that has received Telemedicine services in the past. Patients appropriate for Hem/Onc Telemedicine services are stable patients on oral chemotherapy, per Telehealth Service Agreement. Data will be collected from only 30 patients. Since the survey is optional, once 30 patients have voluntarily responded to the questions, data collection will stop.

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:__LeeAnn Heim____________________

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 [X] No

3. 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	No. of Respondents	Participation Time	Burden
Individual/Households	30	5	2.5
Totals			2.5

FEDERAL COST: The estimated annual cost to the Federal government is _$45.58_________

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? [ ] Yes [ X] 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?

Patients will be offered the opportunity to provide satisfaction feedback following a Tmed Hem/Onc appointment. Patients are eligible if they have completed a Tmed Hem/Onc appointment either on the same day as they completed the satisfaction survey or previous to survey completion. Patients will continue to be offered the opportunity to provide satisfaction survey results until 30 surveys have been completed. There are no other selection criteria. If a veteran declines to participate, and remaining surveys are yet to be collected, veterans that decline will not be solicited again for survey participation.

Administration of the Instrument

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

[X] Web-based or other forms of Social Media (Telemedicine Technology)

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

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

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