Multiple Sclerosis Center of Excellence (MSCoE) Outpatient Clinic

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

TITLE OF INFORMATION COLLECTION:

Multiple Sclerosis Center of Excellence (MSCoE) Outpatient Clinic
Patient Satisfaction Survey

PURPOSE:

The VA Multiple Sclerosis Center of Excellence (MSCoE) will conduct a standardized patient satisfaction survey questionnaire across the MSCoE hub sites in Veterans Integrated Service Networks (VISNs) 1 – 11. The survey, which will ask patients to go onto surveygizmo.com and answer 11 questions, will allow MSCoE to measure current performance and improve quality of services based on patient feedback. No personally identifiable information will be asked, collected, or stored. Patient responses will be utilized internally within MSCoE, and will not be shared publicly or utilized for research purposes.

DESCRIPTION OF RESPONDENTS:

Respondents of the survey will consist of Veteran patients in VISNs 1 – 11 who are seen by MS specialists at MSCoE hub sites. Based on our diagnosis related information, there are 13,500 Veterans with MS in VISNs 1 – 11 and we anticipate a best case scenario of 40% response rate, which correlates to 5,400 respondents.

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: Robert A. David

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 10-211003	5,400	15 minutes	1,350 hrs
Totals			1,350 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? [ ] 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?

Respondents will consist of Veteran patients seen at MSCoE hub sites in VISNs 1 – 11. All MS patients seen by specialists at the 32 MSCoE hub sites will be asked to complete the survey; no sampling will be done in conjunction with this survey.

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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