OMB No. 0917-0036, Supporting Statement for IHS Chinle Service Unit Customer Experience Survey, Division of Public Health

Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

(OMB Control Number: 0917-0036)

TITLE OF INFORMATION COLLECTION: OMB Form No. 0917-0036: IHS Chinle Service Unit Customer Experience Survey, Division of Public Health.

PURPOSE: The IHS goal is to raise the health status of the American Indian and Alaska Native people to the highest possible level by providing comprehensive health care and preventive health services.

To support the IHS mission, the Chinle Service Unit (CSU) provides comprehensive outpatient and inpatient health care to a population of 35,000 Native Americans in the central region of the Navajo Nation. The service unit is made up of the Chinle Comprehensive Health Care Facility (inpatient and outpatient services), Tsaile Health Center, Pinon Health Center, and Many Farms and Rock Point clinics.

In order to assess customer experience with the public health services, “Customer Experience Surveys” are offered to patient-customers in a variety of public health settings. The voluntary surveys are completed on paper (with assistance and/or translation if needed). Each survey includes the same standard 3 questions to assess overall satisfaction, self-reliance and self-impression of health status. Participating departments have additional survey questions tailored to provide focused patient-customer feedback on the program’s services. As a result, there are 8 different survey questionnaires monitoring performance in seven different programs across 5 departments.

No specific identifying information is requested. The information gathered will be used by agency management and staff to identify strengths and weaknesses in current service provision, to plan and redirect resources, to make improvements that are practical and feasible, and to provide vital feedback to partner agencies, tribal leaders, system operators, health boards, and community members regarding customer satisfaction or dissatisfaction with CSU services.

The attached surveys are provided in .pdf displays, with all questions included.

DESCRIPTION OF RESPONDENTS: Patients presenting for outpatient services or clients presenting for non-direct patient care services at any of the CSU sites.

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: web-surveys

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: ­Jill Moses, MD, MPH, Director, Division of Public Health

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: Patients/Clients visiting the following clinics or programs	No. of Respondents	Participation Time	Annual Burden Hrs.
Adolescent School Health	3600	3 minutes	180 hrs
Community Nutrition	1800	3 minutes	90 hrs
Diabetes	2400	3 minutes	120 hrs
Health Promotion	1200	3 minutes	60 hrs
Native Medicine	2400	3 minutes	120 hrs
Public Health Nursing – for Patient	3000	3 minutes	150 hrs
Public Health Nursing – for Patient Care Giver	600	3 minutes	30 hrs
Wellness Center	1200	3 minutes	60 hrs
Totals	16200/annual	3 minutes	810 hrs annually

FEDERAL COST:

Category of Respondent	No. of Respondents	Staff time (1 min/survey)	Supply cost ($.02/survey)
Adolescent School Health Survey	3600	60 x $20.32 =$1219.20	$ 72.00
Community Nutrition – Food Demo Survey	1800	30 X $20.32 = $609.60	$ 36.00
Diabetes Services Survey	2400	40 X $20.32 = $812.80	$ 48.00
Health Promotion Survey	1200	20 X $20.32 = $406.40	$ 24.00
Native Medicine Survey	2400	40 X $20.32 = $812.80	$ 48.00
Public Health Nursing - Patient	3000	50 x $20.32 =$1016.00	$ 72.00
Public Health Nursing – Patient Care Giver	600	10 X $20.32 = $203.20	$ 12.00
Chinle Wellness Center Client Survey	1200	20 X $20.32 = $406.40	$ 24.00
Total	16200	$5486.40	$324.00

FEDERAL COST: The estimated annual cost to the Federal government is $5486.40 for staff (paid at a GS 09 level of $20.32 per hour) and supplies $324.00. Total amount $5810.40.

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 [X ] 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?

Sampling Plan: Varies by program. Adolescent School Health, Community Nutrition, Diabetes, Health Promotion, and Native Medicine conduct a census survey offering questionnaire to all clients who present. Public Health Nursing and Wellness Center conduct single stage cluster surveys by offering the questionnaire to every patient/client seen during four randomly selected days a month.

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? [X ] Yes [ ] No

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

Instructions for Completing Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

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 a statement to that effect in your explanation. Please include how the information will be used to improve services or the program.

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. Provide the name of the individual who is the lead contact and responsible for the collection.

Personally Identifiable Information: Provide answers to the questions. Note: Agencies/Programs 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. If you request PII, please ensure that you state the reason why it is being collected (i.e., in order to respond to inquiries from the participants).

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 (minutes).

FEDERAL COST: Provide an estimate of the annual cost (and description) to the Federal Government. Please provide a brief break down of the costs, including wages for staff utilizing OPM pay scale table. See http://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2015/GS_h.pdf

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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