JOES-Walk-in Contraceptive Clinic Survey_10.4.2024

Joint Outpatient Experience Survey – Walk-in Contraceptive Clinic

OMB CONTROL NUMBER: XXXX-XXXX

OMB EXPIRATION DATE: XX/XX/XXXX

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, [Insert OMB Control Number], is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PRIVACY STATEMENT

Providing information in this survey is voluntary. There is no penalty nor will your benefits be affected if you choose not to respond.

However, maximum participation is encouraged so that the data will be complete and representative. Your survey response will be treated as confidential, identifying information will be used only by persons engaged in, and for the purposes of, the survey research.

However, if during this survey you indicate a direct threat to harm yourself or others, we are required to forward information about that threat to appropriate authorities for action, which will likely include their contacting you.

Question 1:

Overall, I am satisfied with the healthcare I received on this visit.

Please select only one answer for each item

Strongly Disagree

Somewhat Disagree

Neither Agree nor Disagree

Somewhat Agree

Strongly Agree

Question 2:

Approximately how long did you wait in the Walk-in Contraceptive Services Clinic until you were assisted by a staff member?

Please select one answer

Less than 15 minutes

15-30 minutes

31-45 minutes

More than 45 minutes

Question 3:

Was this wait time acceptable to you?

Yes

No

Question 4:

Is this your first encounter with Walk-in Contraceptive Services?

Yes

No

Questions 5 to 8:

For each of the following, please indicate how much you agree or disagree with the statement.

Please select one response for each item

Strongly disagree

Somewhat disagree

Neither agree nor disagree

Somewhat agree

Strongly agree

Access to contraception care is improved by having this Walk-in Contraceptive Clinic.

All of my contraceptive needs were met today.

All of my contraceptive questions were answered today.

I would recommend the walk-in contraception services provided at this facility to my friends who are TRICARE prime eligible.

Question 9:

Please tell us anything that could be done to make the Walk-in Contraceptive Services better. Please do not provide any personally identifiable information in your response.

[TO SHOW IN A LINK ON EACH WEBPAGE:]

PRIVACY STATEMENT

This statement serves to inform you of the purpose for collecting personal information as required by the Privacy Act of 1974, as amended, and how that information will be stored and used.

AUTHORITY: 5 U.S.C. 301, Departmental Regulations; 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; Public Law 104-191, Health Insurance Portability and Accountability Act of 1996; 10 U.S.C., Ch. 55, Medical and Dental Care; 45 CFR 164, Security and Privacy; Department of Defense (DoD) Instruction 6015.23, Foreign Military Personnel Care and Uniform Business Offices in Military Treatment Facilities (MTFS); DoD Manual 6025.18, Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule in DoD Health Care Programs; and E.O. 9397 (SSN), as amended.

PURPOSE: The JOES Survey Suite is a survey system used by the military to gather feedback about outpatient care. The surveys help measure patient satisfaction and guide efforts to make the health system better.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended, these records may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. § 552a(b)(3) as follows: to contractors and others performing or working for the Federal Government when necessary to accomplish an agency function related to this System of Records; For a complete listing of the Routine Uses for this system, refer to the below hyperlinked SORN.

Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Rules, as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.

APPLICABLE SORN: EDHA 07, Military Health Information System (June 15, 2020; 85 FR 36190) https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/DHA/EDHA-07.pdf

DISCLOSURE: Voluntary, Completing the Survey is voluntary; you may stop the Survey at any time and skip any questions you choose. There is no penalty if you choose not to respond, although maximum participation is encouraged so the data will be complete and representative.