Generic Request Form

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

TITLE OF INFORMATION COLLECTION: Patient Survey for Rehabilitation and Audiology Services

PURPOSE: To obtain patients’ perspectives on the care they received in the physical, occupational, speech or audiology departments.

DESCRIPTION OF RESPONDENTS: Random sampling of patients for each service that received care in the last 6 months.

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: Angela Washenitz, PT, DPT Supervisor of Rehabilitation and Audiology Services

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

Personally Identifiable Information:

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

Will be accessing patient charts only to obtain phone number and to see when the received rehabilitation/audiology services.

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
Rehabilitation or Audiology Patients	20 per month	15 min each	60
Totals	240	15	60

FEDERAL COST: The estimated annual cost to the Federal government is _0.00________

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?

I am able to pull up a list of patients for a given time frame for each clinic in the above services. I plan on utilizing a system of calling every 3^rd or every 5^th patient on the list to ensure randomization

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? [ ] Yes [X ] No

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

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