Fast Track Submission Form_ED PQI feedback

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number:0935-0179)

TITLE OF INFORMATION COLLECTION: ED PQI Feedback Survey

PURPOSE: Obtain user feedback on the newly released quality indicator module, Emergency Department Prevention Quality Indicators (ED PQI).

DESCRIPTION OF RESPONDENTS:

Users of the AHRQ Quality Indicators

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[X ] 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:__Whitney Schott______________________________________________

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, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [ X] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [X] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?

[ ] Yes [ X] No

Category of Respondent: (the options here are Public Sector or Private Sector, or both)

Both

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time (hrs)	Burden (hrs)
QI Users (private sector)	50	20/60	17
Totals	50	na	17

FEDERAL COST: The estimated annual cost to the Federal government is $365________

Grade	Number of Hours	Value
GS 13	4	$215
GS 15	2	$150
Total	6	$365

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?

We will notify potential respondents by (1) releasing a survey announcement and link on the OC listserv and (2) posting a survey announcement and link on the AHRQ QI website. There were 453 downloads within the first month of the newest version of AHRQ QI software; we anticipate this is the universe of the type of users that would be interested in downloading the new ED PQI measures. Of those, we anticipate engagement with the online survey to be roughly 10%, estimated at about 50 respondents.

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.