Generic Clearance Request

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

TITLE OF INFORMATION COLLECTION:

Shared Decision Making for Aging Veterans and Families: Program Improvement Questionnaire Telephone Call

PURPOSE:

Assess the extent to which Shared Decision Making is taking place at VA medical center and community based outpatient clinic demonstration sites, and its value to Veterans and their families. This information will facilitate quality improvement of Shared Decision Making programs in VHA.

Shared Decision Making is a collaborative approach to decision making which has been established as a best practice for high quality, Veteran-directed experience. This is of high value to VHA. Funding for implementation to date has been primarily from the Office of Geriatrics and Extended Care, with additional financial support from the Office of Rural Health and the Office of Patient Centered Care and Cultural Transformation. Many additional collaborations support this work including a close relationship with Care Management and Social Work Services.

The burden of time and staffing is incorporated in the project budgets as funded.

DESCRIPTION OF RESPONDENTS:

1. Veterans who have participated in Shared Decision Making at a VA implementation site

2. Family or informal (unpaid) caregiver of these Veterans

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: Laura Taylor, LSCSW, National Director, Social Work, Veterans Health Administration.

____________________________________________

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

Personally Identifiable Information:

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

We are given names and contact information in order to call the Veteran or family, as described below under Selection. We, however, do not link responses to that contact information, and the contact information is kept in a data file completely separate from the responses. Once a Veteran or family member has responded to our questions, or has chosen not to respond, their name is deleted from our records.

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No NA

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No NA

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
Veterans	Up to 50	10 minutes (.167 hours)	8.35
Family or Informal Caregiver of Veterans	Up to 100	10 minutes (.167 hours)	16.7
Totals	150		25.05

FEDERAL COST: The estimated annual cost to the Federal government is __None, included in current project budget and staff responsibilities__________

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?

When social workers at project implementation sites use the SDM process to discuss long term services and supports with Veterans and their families, they ask the Veteran and/or family member of that person if they would be willing to be called on the phone and asked questions about their experience with the process. If the person says yes, then their name and contact information is sent to project staff (GRECC, VA Puget Sound) via encrypted email. The Veteran or family member is then called, up to three times, to arrange a time to ask the attached questions.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ X ] 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.

All are attached.

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Submit all instruments, instructions, and scripts are submitted with the request.

6