ICR Template A11 Section 280 Clearance Outpatient Healthcare Visit Adding Whole Health Questions

Rev. 8/6/2025

Request for Approval under the “Generic Clearance for Improving Customer Experience: OMB Circular A-11, Section 280 Implementation”

(OMB Control Number: 2900-0876)

TITLE OF INFORMATION COLLECTION: Outpatient Health Care Visit – Adding Whole Health Questions

TYPE OF ACTIVITY

Select all that apply.

☐Screener (for example, distributed before or during a usability testing session or other kind of session)

☐Question script for interview, focus group, discussion group, etc. Scripts for usability testing sessions are, in general, exempt from PRA review subject to the caveats on page 3 of this OMB Memorandum.

☒Survey to obtain feedback immediately following a transaction - limited to 15 questions and 5-minutes of burden maximum.

☐Other survey

TYPE OF SUBMISSION

☐New collection: Select this if you do not already have an approved collection.

☒Change to an already approved collection: Select this if you have an already approved collection but are making changes to the questions, the number of respondents, etc.

Please attach your instrument as a separate document using the Word template that pertains to your particular engagement, i.e., either a survey/screener or script. OMB has prepared special templates that must be used for submitting your instrument. Please ask your agency’s PRA officer for these templates. Do not paste the question list within this document. As a reminder, usability testing session scripts are, in general, exempt from PRA review subject to the caveats on p.3 here, but screeners for those sessions must be submitted for PRA review.

PURPOSE OF COLLECTION:

What are you hoping to learn / improve? How do you plan to use what you learn to support service delivery improvement activities? Are there artifacts (user personas, journey maps, digital roadmaps, summary of customer insights to inform service improvements, performance dashboards) the data from this collection will inform?

The Department of Veterans Affairs routinely surveys Veterans Health Administration (VHA) Outpatient Services through the customer feedback survey known as Veterans Signals (VSignals). When Veterans respond to Outpatient Services Surveys, they provide responses to Likert-scale questions as well as an optional free-text comment. One of the Likert-scale questions asks Veterans how they trust the VA on a scale from 1 (Strongly Disagree) to 5 (Strongly Agree). Trust is measured at the nation-wide, hospital network, and individual VA Medical Center level.

The Department of Veterans Affairs would like to add three additional questions regarding the customer experience for Whole Health Treatment when a Veteran has one of those appointments. to the previously approved outpatient healthcare visit survey The questions would only be sent to patients who had a Whole Health Appointment with the Veterans Health Administration. The data collected from these questions will help the Veterans Health Administration better serve Veterans who seek whole health treatment.

ACTIVITY DETAILS

1. If this is a survey for a High Impact Service Provider, will the results of this survey be reported to OMB as part of quarterly reporting obligations?

☐Yes

☒No

☐Not applicable

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

☐Social Media

☒Website

☐Telephone

☐In-person

☐Video conference (e.g., Zoom, WebEx, Teams, etc.)

☐Mail

☐Other, Explain      

3. If this is a survey OR a screener, what platform will be used (e.g., Medallia, Microsoft Forms, Qualtrics, SurveyMonkey, Touchpoints, etc.) VSignals (Medallia)

4. Who will you collect the information from?

Please describe exactly how you will select the people who you will invite to take the screener or survey, or to participate in the session. Some examples:

• If you are requesting approval for a survey that will appear as a “feedback button” on a website, you can write: “100% of people who visit the website will have the opportunity to take the survey, since the invitation appears on each page of the website.”

• If you are requesting approval for a focus group to conduct discovery phase research, you can write: “of the people who provided their email address to the call center rep, 15% of them will be selected at random to be invited to take part in the focus group.”

These are just examples. The key is you must describe the exact methodology you used to determine who gets the invitation to take part in the screener/survey/session.

The Target population is Veterans who have a whole health appointment with the Veterans Health Administration.

5. Please describe the activity or methodology

Describe the information collection activity – e.g., what happens when a person agrees to participate? Will facilitators or interviewers be used? What’s the format of the interview/focus group?

The activity will be an electronic survey that takes 3 minutes to complete.

• How will you ask a respondent to provide information?

(e.g., after an application is submitted online, the final screen will present the opportunity to provide feedback by presenting a link to a feedback form / an actual feedback form)

The Veteran will be emailed with a link to the survey within a week of their appointment.

• When will the activity happen?

Describe the time frame or number of events that will occur (e.g., “We will conduct focus groups on May 13, 14, 15 of XXXX (year)”; “We plan to conduct customer intercept interviews over the course of the summer of XXXX (year) at the field offices identified in response to #2 based on scheduling logistics concluding by Sept. 10^th”, or “This survey will remain on our website in alignment with the timing of the overall clearance.” If you are uncertain as to how long it will take to complete your research, you can write: “Until all participants complete/are interviewed.”)

The survey will be emailed to Veterans that had a whole health appointment within a week of their appointment

6. Will you be compensating participants?
   It may be appropriate to compensate participants for reasonable out-of-pocket costs and to recruit those who are hard to reach, such as those with multiple jobs or are caretakers. It is not appropriate to compensate those participating in their work capacity and those who are vulnerable to coercion or undue influence such as children and people with certain mental disabilities.

☐Yes

☒No

If yes, please describe: (1) the dollar amount and the type of compensation (e.g., gift card) per participant; (2) the reason you are compensating; and (3) why you believe no one in your sample is vulnerable to coercion or undue influence.

N/A

Personally Identifiable Information

Please complete the following questions in coordination with your agency’s privacy office to ensure that the information collection complies with any applicable requirements under the Privacy Act of 1974 (5 U.S.C. § 552a) and other laws and policies:

1. Could any of the questions offer the opportunity for respondents to provide personally identifiable information (PII)?¹

☐Yes

☒No

2. If the answer to Question 1 is “Yes,” will the information collected be covered by the Privacy Act of 1974?

☐Yes

☐No

3. If the answer to Question 2 is “Yes,” what is the status of the applicable system of records notice(s) (SORNs)?

☐ Published (include citation here) and no modification needed. Include citation:      

☐ Published (include citation here), but modification needed. Include citation:      

☐ No SORN exists; need to publish new SORN(s)

4. If a privacy impact assessment (PIA) is required, please provide a link to where the PIA is published on the agency’s website: N/A

BURDEN HOURS

IF YOU SELECTED “NEW COLLECTION” IN RESPONSE TO “TYPE OF SUBMISSION” ON PAGE 1:

Please fill in each applicable cell in the table below.

IF YOU SELECTED “CHANGE TO AN ALREADY APPROVED COLLECTION” IN RESPONSE TO “TYPE OF SUBMISSION” ON PAGE 1:

First, you must figure out whether your change will affect the number of respondents per year or the participation time for the instrument.

• If the number of respondents and the participation time are both staying the same: input “1” for “No. of Respondents per year,” input 60 for “Participation Time in minutes,” and input “1” for “Total Burden per year in hrs.” This is because “1 hour” is the minimum that can be inputted into ROCIS for total burden hours.

• If the number of respondents or the participation time is changing: Contact the CX Desk Officer before completing this table.

Type of Instrument	No. of Respondents per year	Participation Time in minutes	Total Burden per year in hrs
Screener (e.g., distributed before or during a usability testing session or other kind of session)	     	     	     
Question script for focus group, interview group, etc. See discussion of usability testing on page 1.	     	     	     
Survey to obtain feedback immediately following a transaction	5,000	3 minutes	250 hrs
Other survey	     		     
Totals	5,000	3 minutes	250 hrs

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

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. Personally identifiable information (PII) is collected only to the extent necessary and is not retained.

5. Information gathered is intended to be used for general service improvement and program management purposes.

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.

7. All or a subset of information may be released as part of A-11, Section 280 requirements on performance.gov. Additionally, summaries of the data may be released to the public in communications to Congress, the media and other releases disseminated by VEO, consistent with the Information Quality Act.

Name of Person(s) who developed the screener/question script/survey: Todd Stawicki

Email address of the above person(s): todd.stawicki@va.gov

1 PII could include, but is not limited to, name, email address, phone number, or any other information that could be used to distinguish or trace an individual’s identity, either alone or when combined with other information that is linked or linkable to a specific individual.

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