Teledermatology Imaging Patient 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:

Teledermatology Imaging Patient Satisfaction Survey

PURPOSE:

Collection of this information is required to enhance better service delivery for Teledermatology Imaging (TDI) patients. The data will be collected by the Office of Telehealth Services, Boston Telehealth Training Center in Boston, MA (OTS BTTC). The hypothesis will be tested to determine if the TDI service is attributed to the satisfaction of the veteran and shared with the sites to allow enhancement of service delivery.

DESCRIPTION OF RESPONDENTS:

The respondent universe is currently 58,000 (rounded) unique veterans that are currently utilizing TDI programs across the nation at the end of FY13. The TDI lead distributes the blank survey tools to the actual point of care sites within the network on a quarterly basis.

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: __Rebecca Lamkin___________

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 & Households	10,000	2 minutes	333 hours
VA Form 10-211016
Totals			333 hours

FEDERAL COST: The estimated annual cost to the Federal government is $11,000.00

All costs associated with collection of the response data to the survey, calculation of averages and display of the data on a web site is accomplished electronically. There was a one-time cost in FY11 to purchase the Teleform software program and RightFax to capture of the responses.

Programming Teleform for scanning, data capture, calculations and display:

GS11 salary $31.48/hour x 250 hours= $7870

The other cost is an annual support contract for the Teleform software, at $3,140.85.

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?

Patients will be identified at the time of their TDI visit. A random sample will be chosen for two weeks each quarter. The Telehealth Clinical Technician (TCT) or designee located at the point of care sites in the VISN administers the satisfaction survey to patients following their TDI encounter.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[x] 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.

3