Fast-Track Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0668 ExpDate: 02/2019)

T ITLE OF INFORMATION COLLECTION: Patient Satisfaction Questionnaire

PURPOSE:

The Laboratory of Clinical Infectious Diseases (LCID) at the National Institute of Allergy and Infectious Diseases (NIAID) is researching patients with rare immune defects through natural history studies. These patients are generally chronically ill and require complex medical care. Historically, patients requiring more complex medical care are less satisfied with the health care they receive because of quality, cost, and access to providers. LCID is interested in knowing patient satisfaction with the healthcare they receive from our research team compared to the healthcare they receive at home. LCID would use this information for performance improvement of the research team. This survey would assess five areas: general satisfaction; technical quality; interpersonal manner; communication, financial aspects; time spent with doctor; and accessibility and convenience which would specifically identify areas from improvement. Improving patient satisfaction would increase both patient outcomes and patient retention.

DESCRIPTION OF RESPONDENTS:

Potential survey respondents are adult (aged 18 and over) research participants enrolled in an active protocol under the Laboratory of Clinical Infectious Diseases. This patient satisfaction questionnaire is not considered part of the protocol nor will it be used for research purposes.

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: Samantha Kreuzburg, RN

DHHS, NIH, NIAID, LCID

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

3. If Applicable, has a System or Records Notice 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

ESTIMATED BURDEN HOURS and COSTS

Category of Respondent	No. of Respondents	No. of Responses per Respondent	Time per Response (in hours)	Total Burden Hours
Individuals	100	2	4/60	13
Totals	100	200	4/60	13

Category of Respondent	Total Burden Hours	Wage Rate*	Total Burden Cost
Individuals	13.3	$21.32	$285.68
Totals	13		$285.68

* http://www.bls.gov

FEDERAL COST: The estimated annual cost to the Federal government is $1,831

Staff	Grade/Step	Salary	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight	13/3	$95,217	1/52		$1,831
Contractor Cost
Travel
Other Cost
Total:					$1,831

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?

All adult patients seen in our outpatient clinic over a four week period will be asked if they would like to participate in the survey. Each patient would be asked to fill out two surveys: one assessing the healthcare they received from LCID and one assessing the healthcare they receive at home.

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? [ ] Yes [x] No

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

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