One Pager Justification

Request for Approval under the “Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery” (OMB Control Number: 0704-0553)

TITLE OF INFORMATION COLLECTION: Naval Hospital Rota Access to Care Survey

PURPOSE: This short customer survey is to assess access to care at Naval Hospital (NH) Rota and is part of quality improvement efforts at the military medical treatment facility (MTF). The point-of-service survey will collect information about which hospital departments have issues with access to care and what the specific challenges are. The survey allows patients to provide useful insights on their perceptions with access to care. This short survey (less than 5 minutes completion time) will provide NH Rota with information that is not available elsewhere in order to provide actionable data to improve access across all of the clinical and non-clinical departments.

DESCRIPTION OF RESPONDENTS: Beneficiaries (patients) who are eligible to receive care including but not limited to Active Duty Sailors, Spouses, Retirees, GS Civilians.

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: Jason Galka, PharmD, MBA

LCDR, MSC, USN

Director, Health Care Business

Activity Security Manager

NMRTC Rota, Spain

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

DHA Privacy has advised that no Privacy Act Statement is required because the PII that’s being collected will not be stored in a system of record nor retrieved by a personal identifier.

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
Beneficiaries (members of the public)	250	5 minutes	20.8 hours
Totals	250	5 minutes	20.8 hours

PUBLIC COST: The estimated annual cost to the public is $655.84.

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?

We will provide a survey link/QR code throughout the hospital for patients to access. The survey will be on Microsoft Forms. We will not have a specific respondent list.

Administration of the Instrument

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

[X] Web-based or other forms of Social Media (MS Forms)

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

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