Customer Feedback Fast Track

Request for Approval under the “Voluntary Partner Surveys to Implement Executive Order 12862/Questionnaire and Data Collection Testing, Evaluation, and Research for the Health Resources and Services Administration” (OMB Control Number: 0915-0212)

TITLE OF INFORMATION COLLECTION: Health Center Program Support (HCPS) Customer Service Survey

PURPOSE: The Health Center Program Support (HCPS) Customer Service Survey is a brief survey through which individuals who have submitted inquiries to BPHC can provide their level of satisfaction on the quality of service they received from BPHC. Information received will be used to assess, improve, and augment BPHC’s customer support services.

DESCRIPTION OF RESPONDENTS:

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: Kimberly Hill, Systems Division Director

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 Hours Total
Health Center Program Support (HCPS) Customers	1,844	5 minutes	154
Totals

FEDERAL COST:

The estimated annual cost to the federal government is $1,285.66, which includes $335.53 (6.5 hours from contractor), $229.26 (6.5 hours at the GS-9 level), $467.22 (6.5 hours at GS-14), and $253.65 (3 hours at GS-15 level).

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?

All individuals that have an inquiry marked closed or resolved in Salesforce will have the opportunity to provide feedback on how well BPHC agents have responded to their inquiry. The survey will target individuals that submitted an inquiry through the BPHC Contact Form.

Administration of the Instrument

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

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

[ ] Telephone

[ ] 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.