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: Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division

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 patient, we invite 1-2 patients or patient representatives as Key Informants to participate in designing the research questions that guide the report. In order to be certain our process effectively engages these patient Key Informants and to make sure that the final report answers their questions, we would like to ask them a few questions via an online tool about their experience and about the final report, once the project is completed and the final report has been posted. This information will be used to improve how we work with patients going forward and to improve the usefulness of our reports for patients.

DESCRIPTION OF RESPONDENTS: Patient Key Informants who give input on report design to the EPC Program (applies only to reports that have a Topic Refinement process).

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:_Elisabeth Kato__________

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
Patient Key Informant	40/year	15 minutes	10 hours/year
Totals			10 hours

FEDERAL COST: The estimated annual cost to the Federal government is _$600_

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?

We have a list of all the patients who have participated as Key Informants for our systematic reviews and we intend to invite all of them to respond to the questions (100% sample).

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? [x] Yes [ ] No

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