One Pager Executive Health Services Feedback Survey

Request for Approval under the “Fast Track Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0704-0553)

TITLE OF INFORMATION COLLECTION: Executive Health Services Feedback Survey

PURPOSE: To establish a baseline focused on Senior Leader and enrolled populations’ satisfaction with Executive Medicine/Health Program or Military Treatment Facility’s (MTF) equivalent. The survey results will help identify improvement areas and shape initiatives to incorporate best practices.

DESCRIPTION OF RESPONDENTS: Colonel (O6) promotable and above Commanders and their Command Sergeants Major, and eligible family members and eligible populations’ supported by the MTFs’ Executive Medicine/Health program(s).

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:_MAJ Darien Diaz _______________________________________________

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
Family members	100	5 minutes	8.3 hours
Totals	100	5	8.3

PUBLIC COST: The estimated annual cost to the public is $166

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?

This is a census. The target population group consists of O6 promotable and above Commanders and their Command Sergeants Major, and eligible family members and eligible populations’ supported by the MTFs’ Executive Medicine/Health program(s). We will delegate to the MTFs to distribute the survey via email link. The MTFs have the list of recipients to send the email. The MTFs will send the email invitation to every Executive Health and Medicine patient seen at the Executive Clinic within the past 18 months.

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

[X] Mail

[ ] Other, Explain

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

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