Bereaved Family Member Satisfaction Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-21081(NR) Bereaved Family Member Satisfaction Survey	Form	New	Repair queued
VA Request Memo.doc	Supplementary Document	Uploaded 2007-01-11	Repair queued
Breaved Family OMB NOTICE OF ACTION.txt	Supplementary Document	Uploaded 2006-09-22	Repair queued
Bereaved Family OMB Survey Question Responses.doc	Supplementary Document	Uploaded 2006-09-22	Repair queued
Bereaved Family Sample Cover Letter for Phone Survey.doc	Supplementary Document	Uploaded 2006-09-22	Repair queued
Bereaved Family Sample Cover Letter for Mail Survey.doc	Supplementary Document	Uploaded 2006-09-22	Repair queued
Bereaved Family Mail Survey.doc	Supplementary Document	Uploaded 2006-09-22	Repair queued
Bereaved Family Justification B.doc	Supporting Statement B	Uploaded 2006-09-22	Repair queued
Bereaved Family Justification A.doc	Supporting Statement A	Uploaded 2006-09-22	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
45337	Bereaved Family Member Satisfaction Survey	Form	New

ICR Details

OMB Control No:	ICR Reference No: 200609-2900-006
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Bereaved Family Member Satisfaction Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 01/11/2007
	Date Received in OIRA: 09/22/2006
Terms of Clearance: Withdrawn per VA request memo submitted to OMB 1/11/2007. Upon resubmission OMB shall waive the 60 and 30 day comment periods.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This study is a result of recent veteran death rates combined with VA's strategic plan to focus on patient/family centered care. The purpose of the pilot survey is to determine a feasible administration method. Results will be the driving force for ongoing improvements in the quality of end-of-life care provided in VA.

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Authorizing Statute(s): US Code: 38 USC 527 Name of Law: Evaluation and data collection
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 60	03/29/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 105	06/01/2006
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Bereaved Family Member Satisfaction Survey	10-21081(NR)	Telephone Bereaved Family Member Satisfaction Survey

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection and all burden hours are considered a program increase.

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Annual Cost to Federal Government: $4,041

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/22/2006

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