fast-track-PRA-submission-short-form Patient and Caregiver Survey

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0935-0124)

TITLE OF INFORMATION COLLECTION: Patient and Caregiver Survey

PURPOSE:

In this web-based survey, patients and caregivers will be asked to review their personal health data in the application and answer questions regarding the completeness and accuracy of the data and provide their opinion on the general functionality and effectiveness usefulness of the application.

DESCRIPTION OF RESPONDENTS:

Patients and caregivers will meet the following criteria:

• At least 18 years of age

• Have more than one diagnosed chronic condition (or be a caregiver to a patient with multiple chronic conditions)

• Have experience using the patient portal

We will also selectively target patients and caregivers who also receive care at a designated health system EHR target site. These target sites may include Providence (Epic), OCHIN (Epic), NextGen sites, and the U.S. Department of Veterans Affairs’ VistA system.

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 based survey______

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:_____________Jacqueline Ortiz__________________________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [X] Yes [ ] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [X] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [X] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [X] Yes [ ] No

Respondents will receive a $25 Amazon gift card to incentivize their efforts. This amount is close to the $29.76/hour listed for 00-0000 All Occupations in the National Compensation Survey: Occupational wages in the United States (May 2022).

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals	90	1 hour	90 hours
Totals	90	1 hour	90 hours

FEDERAL COST: The estimated annual cost to the Federal government is $2,250.

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?

Subjects may be recruited through multiple avenues. Initially we will work with clinicians who are interested or involved in the project. We will ask them to identify patients who may be a good fit, then study team members will reach out through email or telephone.

We also intend to utilize the OHSU Clinical Research Council’s Community Insights Panel to draw eligible participants from a pool of individuals who have already agreed to be contacted about research participation. This will involve sending out a short screening survey that potential participants will complete via the web. All responses will be collected in a spreadsheet which will be screened by the Clinical Research Council. Potential participants who do not meet the inclusion criteria will be removed. The spreadsheet will, then, be passed along to our research team.

Upon meeting inclusion criteria, and expressing interest in participating, patients will be assigned, in the order of recruitment, to either the interview or survey group. That is, the first 2-4 patients who express interest in any given phase will be interviewed, and the rest will receive the survey.

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

[ X] Other, Explain: Webex, a video call service

1.a. Percentage reporting electronically [100]

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

Please make sure 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 Routine Customer Feedback”

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 this in your explanation.

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.

Personally Identifiable Information: Provide answers to the questions. Note: Agencies 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.

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

BURDEN HOURS:

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 (in minutes) 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 Respondents and the Participation Time then divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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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