Survey of Healthcare Experiences Dental Patient Satisfaction Survey

Forms and Documents

Document Name	Status
Form VA Form 10-0503 Survey of Healthcare Experiences of Patients, Dental Patient Satisfaction Survey Form and Instruction	New
CAHPS Supplemental Items for Adult Questionnaire.pdf Supplementary Document	2011-02-08
Post SurveyThank You letter.doc Supplementary Document	2010-07-06
Pre-Survey Letter.doc Supplementary Document	2010-07-06
10-0503_Justification B final.docx Supporting Statement B	2011-02-08
10-0503 Justification.doc Supporting Statement A	2010-07-27
ADA Trends - Development and Testing of a Survey Instrument....pdf Supplementary Document	2010-03-24

IC Document Collections

IC ID	Document Title	Status
192326	Survey of Healthcare Experiences of Patients, Dental Patient Satisfaction Survey Form and Instruction	New

ICR Details

OMB Control No: 2900-0764	ICR Reference No: 201003-2900-014
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Survey of Healthcare Experiences Dental 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: 02/25/2011
	Date Received in OIRA: 07/27/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2014	36 Months From Approved
Responses	36,585	0	0
Time Burden (Hours)	9,146	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The overall purpose of the VHA Office of Dentistry Dental Patient Satisfaction Survey is to systematically obtain information from patients that can be used to identify problems or complaints that need attention and to improve the quality of dental health care services delivered to Veterans. The Office of Dentistry (OOD) currently tracks a number of clinical parameters indicative of quality care (e.g., appropriate use of fluoride products in high caries risk patients, frequency of dental examinations and care provided to medically compelling patients); however, patient satisfaction with this care is not specifically measured. The mission of the Veterans Health Administration (VHA) is to provide high quality medical and dental care to eligible veterans.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

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 63	04/02/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 109	06/08/2010
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Survey of Healthcare Experiences of Patients, Dental Patient Satisfaction Survey	VA Form 10-0503	Survey of Healthcare Experiences of Patients, Dental Patient Satisfaction Survey

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ICR Summary 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	36,585	0	0	36,585	0	0
Annual Time Burden (Hours)	9,146	0	0	9,146	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, therefore all burden hours are considered an increase.

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Annual Cost to Federal Government: $300,000

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: 07/27/2010

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