0917-0036, Mini-supporting Statment for CSU Employee Survey

Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

(OMB Control Number: 0917-0036)

T ITLE OF INFORMATION COLLECTION: OMB Form No. 0917-0036: Chinle Service Unit (CSU) Employee Satisfaction Survey.

PURPOSE:

To support the IHS mission, the information obtained from the employee satisfaction survey provides feedback to staff about employee experience of care. The information gathered will be used to gage employee satisfaction and to make practical and feasible improvements in the environment.

DESCRIPTION OF RESPONDENTS:

The Employee Satisfaction Survey is offered to employees on a voluntary basis, semi-annually during the calendar year. Surveys are administered by Survey Monkey to all staff via email. The survey contains a total of 22 questions which employees respond based on their experience, that pertain to job satisfaction, communication, customer service, overall health, and workplace environment.

TYPE OF COLLECTION: (Check one)

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

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

[ ] Focus Group [ X] Other: web-surveys

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: Tom Lefebvre, MHA, Director, Quality Management

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	AnnualBurden Hrs.
CSU Employees	1200 semi-annually	6 minutes	120 hrs.
	1200 semi-annually	6 minutes	120 hrs.
Totals	2400/ yr	12 minutes	240 hrs

FEDERAL COST: The estimated annual cost to the Federal government is $1000.

If 1200 surveys are completed twice a year and 2400 surveys collected overall, then it will take approximately 40 hours each year to gather information and report results. A GS 9 rate of about $25 per hour x 40 hrs. = $1000 per year.

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?

The CSU Employee Satisfaction Survey is administered to all individuals working at CSU, includes: permanent employees, temporary employees, contractors, volunteers, emergency hires); excludes Tribal and non-IHS employees.

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 ensure that all instruments, instructions, and scripts are submitted with the request.

Instructions for Completing Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request (e.g., Comment card for soliciting feedback on xxxx).

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include a statement to that effect in your explanation. Please include how the information will be used to improve services or the program.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved. Provide the name of the individual who is the lead contact and responsible for the collection.

Personally Identifiable Information: Provide answers to the questions. Note: Agencies/Programs should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective. If you request PII, please ensure that you state the reason why it is being collected (i.e., in order to respond to inquiries from the participants).

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS: 77.6 hrs.

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households; (2) Private Sector; (3) State, local, or Tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. of Respondents: Provide an estimate of the number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group).

Burden: Provide the annual burden hours: Multiply the number of responses and the participation time and divide by 60 (minutes).

FEDERAL COST: Provide an estimate of the annual cost (and description) to the Federal Government. Please provide a brief break down of the costs, including wages for staff utilizing OPM pay scale table. See http://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2015/GS_h.pdf

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: Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Submit all instruments, instructions, and scripts are submitted with the request.

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