Desription Consumer Directed Exchange Feasibility Study Questionnaire

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0960-0788)

TITLE OF INFORMATION COLLECTION: Consumer Directed Exchange Feasibility Study Questionnaire

PURPOSE: The purpose of this questionnaire is to assess the state of the marketplace regarding consumer directed exchange, and the patient’s rights to view, download, and transmit personal medical health records. The Office of Information Technology Programmatic Business Support (OITPBS) wants to take an in-depth look at consumer directed exchange and the current adoption in the medical evidence marketplace. The Consumer Directed Exchange Feasibility Study Questionnaire will assist SSA in determining the potential future integration of consumer directed exchange into the business process of collecting medical evidence for disability case processing.

DESCRIPTION OF RESPONDENTS: The respondents of the Consumer Directed Exchange Feasibility Study Questionnaire are identified healthcare industry leaders. These participants vary from healthcare providers, policy makers, and subject matter experts in the field.

TYPE OF COLLECTION: (Check one)

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

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[X ] 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: Brent Hayward, Contractor on Evidence Acquisition Project, Disability Insurance Benefits, Social Security Administration_________________

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 [ ] No

3. If Applicable, has a System or Records Notice 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 (minutes)	Burden (hours)
Health Care Subject Matter Experts	45	25	19
Totals	45	25	19

FEDERAL COST: The estimated annual cost to the Federal government is $1,836.00

This is a one-time cost, as the survey will not be distributed annually. The total cost is for the creation, collection and processing cost for the contractor for twenty hours of contractor rate.

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?

Yes, customer list is attached.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[X ] Other, Explain - Email

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

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

3