Survey for the Evaluation of the Low Vision Rehabilitation Demonstration (CMS-10218)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Responses to comments.doc	Supplementary Document	Uploaded 2008-04-02	Repair queued
OMB Clearance Package revised 052907.doc	Supporting Statement B	Uploaded 2007-12-17	Repair queued
CMS-10218 Attach #5 LVS Telephone Call Script-12-04-06.doc	Supplementary Document	Uploaded 2007-12-17	Repair queued
CMS-10218 Attach #5 LVS Letter 2 (English)-03-23-07 with disclosure.doc	Supplementary Document	Uploaded 2007-12-17	Repair queued
CMS-10218 Attach #5 LVS Letter 1 (English)-03-23-07 with disclsoure.doc	Supplementary Document	Uploaded 2007-12-17	Repair queued
CMS-10218 Attach #5 LVS Fact Sheet (English)-03-23-07 with disclosure.doc	Supplementary Document	Uploaded 2007-12-17	Repair queued
OMB Clearance Package revised 052907.doc	Supporting Statement A	Uploaded 2007-12-17	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
183401	Physician and Beneficiary Survey for the Evaluation of the Low Vision Rehabilitation Demonstration (Patient interviews)	Other-Telephone Survey	New
183400	Physician and Beneficiary Survey for the Evaluation of the Low Vision Rehabilitation Demonstration (Physician interviews)	Other-Telephone Survey	New
183399	Physician and Beneficiary Survey for the Evaluation of the Low Vision Rehabilitation Demonstration (LVR Provider focus groups)	Other-Telephone Survey	New
183398	Evaluation of the Low Vision Rehabilitation Demonstration (Survey)	Other-Telephone Survey	New

ICR Details

OMB Control No:	ICR Reference No: 200801-0938-006
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Survey for the Evaluation of the Low Vision Rehabilitation Demonstration (CMS-10218)
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OIRA Conclusion Action: Withdrawn	Conclusion Date: 04/09/2008
	Date Received in OIRA: 01/15/2008
Terms of Clearance: CMS has requested to withdraw this collection.

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

---

Abstract: As part of the appropriations conference report that accompanied H.R. 2673, the Secretary of the DHHS is directed to carry out an outpatient vision rehabilitation demonstration project. This information collection relates to the collection of health status indicators for the Project through a survey along with information for a process evaluation. The survey will be conducted among Medicare beneficiaries with low vision and providers of low vision services. The process evaluation includes focus groups with physicians and providers as well as telephone interviews with physicians, providers and patients. CMS intends to conduct the evaluation study over the course of three years (2008 - 2010).

---

Authorizing Statute(s): US Code: 42 USC 1395b-1 Name of Law: Incentives for economy while maintaining or improving quality in provision of health services.
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 57034	10/05/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 71141	12/14/2007
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Evaluation of the Low Vision Rehabilitation Demonstration (Survey)
Physician and Beneficiary Survey for the Evaluation of the Low Vision Rehabilitation Demonstration (LVR Provider focus groups)
Physician and Beneficiary Survey for the Evaluation of the Low Vision Rehabilitation Demonstration (Physician interviews)
Physician and Beneficiary Survey for the Evaluation of the Low Vision Rehabilitation Demonstration (Patient interviews)

---

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: To examine the impact of standardized national coverage for vision rehabilitation services provided in the home by physicians, occupational therapists and certified low vision therapists, rehabilitation teachers, and orientation and mobility specialists.

---

Annual Cost to Federal Government: $316,667

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

---

Common Form ICR:  No

---

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: 01/15/2008

---