Patient Satisfaction Survey Michael E. DeBakey Home Care Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Justification B 2010 (3).doc	Supporting Statement B	Uploaded 2010-09-27	Available
10-0476 Justification A.docx	Supporting Statement A	Uploaded 2011-02-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
194516	Patient Satisfaction Survey, Michael E. DeBakey Home Care Program	Other-Telephonic	New

ICR Details

OMB Control No: 2900-0775	ICR Reference No: 201009-2900-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Patient Satisfaction Survey Michael E. DeBakey Home Care Program
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: 08/12/2011
	Date Received in OIRA: 02/15/2011
Terms of Clearance: Approved for a period of 18 months after which VA shall seek a new approval from OMB, and shall include a report on response rates and the quality of data collected under this collection.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2013	36 Months From Approved
Responses	100	0	0
Time Burden (Hours)	17	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Executive Order 12862, Setting Customer Service Standards, calls for the establishment and implementation of customer service standards, and for agencies to "survey customers to determine the kind and quality of services they want and their level of satisfaction with current services". The Michael E. DeBakey Home Care Program Patient Satisfaction tool will allow for patient objective and anonymous feedback. The Patient Satisfaction survey data is collected by telephone because the patients who are on the home care program are the elderly/frail and Spinal Cord Injury. The intent of this survey is to provide feedback to providers and staff regarding patient satisfaction with services provided by or through the DeBakey home care program staff.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer 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 196	10/12/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 3	01/05/2011
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
Patient Satisfaction Survey, Michael E. DeBakey Home Care Program

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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	100	0	0	100	0	0
Annual Time Burden (Hours)	17	0	0	17	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. All hours are considered a burden increase.

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Annual Cost to Federal Government: $450

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: 02/15/2011

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