Request for Approval - Telebehavioral Health Patient Satisfaction Survey

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

(OMB Control Number: 0917-0036)

TITLE OF INFORMATION COLLECTION: Catawba Service Unit Telebehavioral Health Patient Satisfaction Survey

PURPOSE: The information obtained from the Catawba Service Unit Telebehavioral Health Patient Satisfaction Survey will provide data about the satisfaction rate of our behavioral health program.

DESCRIPTION OF RESPONDENTS: The Telebehavioral Health Patient Satisfaction Survey will be made available to Catawba Service Unit behavioral health patients on a voluntary basis every quarter until 10 responses are received. There is no personally identifiable information on the Telebehavioral Health Patient Satisfaction Surveys. There are 12 questions on the survey; two questions are yes/no questions, one is a circle your preference question, seven are rate 1-5 questions, and two are open ended questions for comments/concerns.

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 (Behavioral Health Patients) [ ] 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: Hollis Reed, RN, BSN, Clinical Nurse Supervisor, Catawba Service Unit

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
Individuals – Behavioral Health Patients at the Catawba Service Unit	40 per year	5 minutes	3.33 hours
Totals	40 per year	5 minutes	3 hours

FEDERAL COST: The estimated annual cost to the Federal government is $26.00.

One staff person spends about 2 minutes on each survey tallying the response rates, collecting the information, and reporting the totals in a reporting template. If 40 surveys are completed yearly, this equals about 1 hour and 23 minutes of staff time. This time is incorporated into the current duties of the staff.

Note –This is a continuous survey that will occur quarterly by our behavioral health patients.

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?

The respondent universe will be patients who are active in one or both of our behavioral health programs at the Catawba Service Unit. This includes the telepsych and telecounseling clinics. Ten behavioral health patients will be asked to complete the survey every quarter but participation will be voluntary.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[X] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [X] No (unless a patient has low-literary skills and requires assistance)

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