Generic Request - Millennium Act

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

TITLE OF INFORMATION COLLECTION:

Veterans Millennium Act Emergency Care Benefit Satisfaction Survey

PURPOSE:

The Community Care Operations Program Office (CCOPO) of the Veterans Health Administration Office of Community Care (VHA CC) will use the information gathered as a result of this survey to focus specifically on the care, provisions and processes associated with Veterans who received emergency treatment in a community medical facility under the Veterans Millennium Health Care and Benefits Act (Millennium Act) emergency care benefit. The resulting data will be used to more effectively tailor the agency’s education efforts and service delivery processes in order to improve Veterans’ satisfaction with emergency treatment received in a community medical facility and increase Veterans’ knowledge of eligibility regarding the Millennium Act emergency care benefit.

DESCRIPTION OF RESPONDENTS:

The pool of respondents will consist of an annual sampling of Veterans who received emergency treatment in a community medical facility under the Millennium Act emergency care benefit, within the 3 months leading up to the annual data extraction.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [] 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: Douglas Katason, Stakeholder Outreach Manager

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

Personally Identifiable Information:

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

BURDEN HOURS

Category of Respondent: Individuals & Households	No. of Respondents	Participation Time	Burden
VA Form 10-XXXXXX (Veterans Millennium Act Emergency Care Benefit Satisfaction Survey)	2,000	7 minutes	233

FEDERAL COST: The estimated annual cost to the Federal government is $18,195.00. Cost includes burden hours ($5,592.00) plus supplies, printing, mailing and processing of the survey ($12,603.00).

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? [ ] 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?

Inclusion criteria:

Sampling will be from all Veterans who received emergency treatment in a community medical facility under the Millennium Act emergency care benefit in the 3 months leading up to the annual data extraction.

Sample size:

The sample size will be a maximum of 10,000 of those Veterans who received emergency treatment in a community medical facility under the Millennium Act emergency care benefit. It is anticipated of the 10,000 surveys sent out each year an estimated response rate of 20 percent will be achieved. The patient names, addresses, services received and dates of service will be extracted from internal VA databases in accordance with existing approved standards ensuring privacy and security of the data.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

A survey invitation letter will be sent to a sampling of Veterans who received emergency treatment in a community medical facility under the Millennium Act emergency care benefit. The invitation letter will contain a Web link to the VA Community Care Web site in order to access the survey instrument which resides in the Web-based survey tool, Survey Monkey. A phone number will also be provided in the letter for the Veteran to request a paper copy of the survey instrument, in lieu of using the Web-based option.

A survey reminder letter will also be sent to the same sampling of Veterans approximately two weeks after the invitation was sent to either remind the Veteran to take the survey or thank them for taking the survey.

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

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