Generic Submission Request_Dental Insurance Program Survey

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

TITLE OF INFORMATION COLLECTION:

Veterans’ Dental Insurance Program Satisfaction Survey

PURPOSE:

The VA Dental Insurance Program (VADIP) is a new program for Veterans enrolled in VA health care and survivors and dependents of Veterans eligible for VA’s Civilian Health and Medical Program (CHAMPVA). VHA seeks to give Veterans an opportunity to provide anonymous feedback on the accessibility and viability of an external dental insurance program. VHA will use the information gathered to assess the feasibility and advisability of a competitive, private, premium-based dental insurance plan for enrolled Veterans. This voluntary survey will not be used as a substitute for traditional program evaluation surveys that measure objective outcomes. The survey will solicit voluntary opinions and are not intended to collect information required to obtain or maintain eligibility for a Department of Veterans Affairs (VA) program or benefit. To maximize the voluntary response rates, the information collections will be designed to be convenient, simple and free of unnecessary barriers.

DESCRIPTION OF RESPONDENTS:

The pool of respondents will consist of Veterans enrolled in VADIP and eligible survivors and dependents for CHAMPVA. This will be a semi-annual survey. The probability of Veterans having access to the public internet is unknown, therefore the Veterans will have an option to complete the survey by calling a specified telephone number or complete a survey on the internet. The survey internet link and telephone number will be available on the Health Benefits website.

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: Venis Whitfield

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	Frequency of Response	Participation Time	Burden
VA Form 10-211011	2120	1.5	15 minutes	795
Totals				795

FEDERAL COST: These cost for print reproduction will be approximately $1,400 per year.

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?

VA, through the Office of Quality Performance, expert staff is available for advising, consulting, and working with individual facilities regarding local survey efforts. VA will use its internal review process at the Office of Quality and Performance (OQP) Durham Office to examine the information collection to prevent duplication of effort or redundancy in all information collected.

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

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

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