Care Coordination Home Telehealth (CCHT) Patient Satisfaction Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CCT Core Conditions of Participation 3-10.docm	Supplementary Document	Uploaded 2010-08-18	Available
CCHT_justification_B_(V3)1.doc	Supporting Statement B	Uploaded 2010-08-18	Available
CCHT justification A (V4).doc	Supporting Statement A	Uploaded 2010-03-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
191713	Care Coordination Home Telehealth Patient Satisfaction Survey	Other-Electronic Survey Questions	New

ICR Details

OMB Control No: 2900-0766	ICR Reference No: 201001-2900-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Care Coordination Home Telehealth (CCHT) Patient 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: Approved with change	Conclusion Date: 03/16/2011
	Date Received in OIRA: 03/31/2010
Terms of Clearance: Approved consistent with revisions submitted by VA and included in the public docket.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2014	36 Months From Approved
Responses	65,600	0	0
Time Burden (Hours)	1,640	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The CCHT satisfaction survey will capture current patients’ perspectives on satisfaction with specific aspects of the program and equipment through an automated method. The survey will be delivered electronically to patients enrolled in the CCHT Program via a messaging device located in the patient’s home. These devices will provide questions to enrolled patients on a small screen and in some cases, the questions are electronically spoken to visually impaired patients through Interactive Voice Response. The patient will select the appropriate answer using either buttons or a touch screen application. Patient satisfaction responses will be captured electronically and reported.

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Authorizing Statute(s): US Code: 38 USC Part 1, Chapter 5, Section 527 Name of Law: Veterans Benefits
  

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:
	75 FR 10	01/15/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 59	03/29/2010
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
Care Coordination Home Telehealth Patient Satisfaction Survey

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	65,600	0	0	65,600	0	0
Annual Time Burden (Hours)	1,640	0	0	1,640	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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 collection and all burden hours are considered a program increase

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Annual Cost to Federal Government: $645

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 03/31/2010

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