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: Public Health Messaging Survey

PURPOSE: The purpose of this survey is to solicit feedback from customers and stakeholders of the Fort Sill Department of Public Health. The responses will be gathered to develop a department marketing plan and health information campaign for the purposes of Health and Wellness/ Disease Prevention.

The survey will be conducted on DHA’s survey platform through Connect.gov Survey.

DESCRIPTION OF RESPONDENTS: Respondents will be select patients of Reynolds Army Health Clinic and Public Health Stakeholders. Surveys will be provided to patients that attend appointments in the clinical areas of Public Health (Armed Forces Wellness Center, Public Health Nursing Clinic, Nutrition Care, and Occupational Health) and to Public Health System stakeholders (Brigade and installation agency POCs) during a 30-day time period to be determined following survey approval.

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: Customer Feedback 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: Jodi Jordan RN, MSN

Public Health Nursing Supervisor

Sexual Assault Care Coordinator

Reynolds Army Health Clinic

Fort Sill, OK

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
Public Health Clinic Customers	200	5 minutes	16.67
Public Health Partners	10	5 minutes	0.83
Totals	210	5 minutes	17.50

PUBLIC COST: The estimated annual cost to the public is $859.

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?

Surveyed patients will depend on individuals who attend a scheduled appointment in the clinical areas named above, and voluntarily complete the survey.

A list of installation organizations POCs will be compiled based on current involvement with those groups within the public health system. The POC from these agencies will include but are not limited to the Integrated Prevention Advisory Group, CR2C Working group, Quality and Safety Department, Child and Youth Services, etc.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[x] In-person (for patients in clinic)

[ ] Mail

[x] Other, Explain: Fillable PDF will be sent by email to Public Health Partners

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

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