Community Pulse Check (CPC) Digital Comment Card Request for Approval

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

TITLE OF INFORMATION COLLECTION:

Community Pulse Check (CPC) Digital Comment Card, formerly known as Community Engagement Digital Comment Card. Questions updated under general control ICR number: 201710-2900-001.

PURPOSE: The updated survey will gauge additional respondents’ perceptions of the VA’s engagement in local communities. The data collected will be used for internal community process improvement activities. This updated comment card supersedes the former CEDCC comment card due to updated CPC Program regulations and guidelines.

DESCRIPTION OF RESPONDENTS:

• Any veteran, active military member, guard/reserve member, family member, caregiver, survivor, VA employee, or CVEB member who interacts with community engagement materials.

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:
Anil Tilbe
Anil.Tilbe@Va.gov

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, 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 [X] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals	9,000 Annual	5 minutes	750 hours
Totals	9,000 Annual	5 minutes	750 hours

FEDERAL COST: The estimated annual cost to the Federal government is 0.

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?

Respondent plan:

1. CPC is intended to be an open survey available for public response 24/7/365.

2. CPC web link will be distributed on a recurring basis to national network of 153 Community Veteran Engagement Boards (CVEB), State and County Departments of Veterans Affairs, Veterans Service Organizations (VSO), and other community stakeholders while requesting continued distribution to their community networks.

3. CPC web link will be distributed to these community partners via QR code, GovDelivery email and text platform, direct email from Veterans Experience Office (VEO) personnel, and permanently available on the VEO website.

Administration of the Instrument

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

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

[X] Telephone

[X] In-person

[ ] Mail

[X] Other, Explain E-mail

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

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

Questions to be asked:

“Which of these terms best represents you?”

Response Type will be Drop-down

“Which state or territory do you live in?”

Response Type will be drop-down

“Which is your nearest VA Medical Center?”

Response Type will be drop-down

“Which is your nearest VA Community-Based Outpatient Clinic?”

Response Type will be drop-down

“Do you live 50 miles or less from a VA healthcare facility?”

Response Type will be Yes/No

“Do you currently receive VA healthcare services?”

Response Type will be Yes/No

“Do you currently receive VA benefits?”

Response Type will be Yes/No

“Are you a member of a CVEB (Community Veteran Engagement Board)?”

Response Type will be Yes/No

“My local community is a supportive environment for Veterans and families to live.”
Response Type will be Likert-scale OR Smiley/Frowny face scale

“A coordinated support system is meant to help Veterans access and receive services through VA and community partners. VA engagement efforts are creating a coordinated support system in my community.”
Response Type will be Likert-scale OR Smiley/Frowny face scale

“Local VA and local community groups are working in partnership to address gaps in services.”
Response Type will be Likert-scale OR Smiley/Frowny face scale

“VA transition support services make it easy for transitioning service members to integrate into the community.”
Response Type will be Likert-scale OR Smiley/Frowny face scale

“Access to VA services and benefits is improving for Veterans in my community.”
Response Type will be Likert-scale OR Smiley/Frowny face scale

“Veterans are able to navigate non-medical VA benefits in my community.”
Response Type will be Likert-scale OR Smiley/Frowny face scale

“Veterans are able to navigate VA healthcare services in my community.”
Response Type will be Likert-scale OR Smiley/Frowny face scale

“Community-based resources are any non-VA healthcare, benefits, and services provided. Access to community-based resources is improving for Veterans in my community.”
Response Type will be Likert-scale OR Smiley/Frowny face scale

“The Community Care program (formerly the CHOICE program) is meeting the healthcare needs of Veterans in my community.”
Response Type will be Likert-scale OR Smiley/Frowny face scale

“Suicide prevention resources are available and accessible in my community.”
Response Type will be Likert-scale OR Smiley/Frowny face scale

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.

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