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: IV Access Patient Survey - Part of the One & Done Initiative

PURPOSE: Conduct a patient satisfaction survey about their general surgery experience, specifically related to a novel IV placement process that reduces multiple needle sticks to a single placement. This short 8-question survey is part of a quality improvement (QI) effort.

DESCRIPTION OF RESPONDENTS: Patients who undergo the 1STIC procedure for IV placement in General Surgery at Alexander T. Augusta Medical Center (ATAMMC).

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:__Dr. Rebecca Rough, DHA Director’s Innovation Group_

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
General Surgery Patients	500	2 minutes	16.7 hrs
Totals	500		16.7 hrs

PUBLIC COST: The estimated annual cost to the public is _$524.67___________

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?

Customers are the patients who are undergoing General Surgery at ATAMMC. Survey is voluntary; patients will be prompted via QR code to provide their feedback as desired. Any patients willing to provide feedback will be accepted. Answers are subjective in nature and will be used to evaluate the perception and benefit of the pilot program in terms of patient experience.

Administration of the Instrument

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

[x] Web-based or other forms of Social Media (Connect.gov Survey platform)

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

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