Supporting Statement Part A

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

T ITLE OF INFORMATION COLLECTION:

Stakeholder Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Program

PURPOSE:

The mission of the EPC program is to create reports that improve healthcare by supporting evidence-based decision making by patients, providers, and policymakers. To ensure that our reports answer the questions that are important to these stakeholders and to facilitate dissemination of our reports, we notify stakeholders at several key points during the systematic review development process. When we are beginning a systematic review, we identify stakeholders who may be interested in the topic. We then notify them via email to let them know we have started working on a topic, when there are opportunities for public comment, and when the review is complete. We want to learn more about their experiences receiving these updates and how we can improve their experiences.

Respondents will be invited to take a brief survey via email. The survey will not collect or store any personally identifiable information from the respondent; it will only collect the name of the systematic review, the organization the respondent is from, and the survey responses.

DESCRIPTION OF RESPONDENTS:

Stakeholders include patients, clinicians, policymakers/payers, healthcare delivery organizations, and others. Stakeholders also include Federal government employees; however, we have not included them in the following calculations.

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:____Amanda Borsky____________________________________________

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
Stakeholders	400 stakeholders x 20 reports/year	0.25 hour	100 hours
Totals	400	0.25	100

FEDERAL COST: The estimated annual cost to the Federal government is __$5,500__________

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 use a population census; not a sample of stakeholders. All stakeholders who are notified about our reports during the year will receive an email invitation to participate in the survey. The survey will not collect any personally identifiable information. It will only collect the survey responses, name of the report, and organization name. The email addresses of stakeholders will be stored completely separately from the survey responses.

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

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