Spinal Cord Injury Patient Care Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-0515 Spinal Cord Injury Patient Care Survey	Form	New	Repair queued
10-0515 Justification A.docx	Supporting Statement A	Uploaded 2012-01-05	Repair queued
Justification_B (v2).doc	Supporting Statement B	Uploaded 2011-08-09	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
198818	Spinal Cord Injury Patient Care Survey	Form	New

ICR Details

OMB Control No:	ICR Reference No: 201108-2900-015
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Spinal Cord Injury Patient Care 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OIRA Conclusion Action: Withdrawn	Conclusion Date: 04/18/2012
	Date Received in OIRA: 01/05/2012
Terms of Clearance: VA withdraws this collection and will resubmit it for review under a generic clearance --OMB control number 2900-0770.

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: VHA requests the ability to obtain feedback by survey for the purposes of determining if the project is meeting the objectives and intent set identified in Executive Order 13410, assessment of the relevancy and usability of the information provided to beneficiaries, enrollees and providers on selected health care measures. As additional measures are added or reports change, additional feedback will be needed. The information collected from spinal cord injury patients will be used by Spinal Cord Injury (SCI) Providers and other Disciplines who are involved in patient care. Any input or information received from patients will be used to improve care and patient needs in addition to patient satisfaction.

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Authorizing Statute(s): EO: EO 13410 Name/Subject of EO: Promoting Quality and Efficient Health Care in Federal
   EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
   US Code: 38 USC Part 1, Chapter 5, section 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:
	76 FR 177	09/13/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 223	11/18/2011
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
Spinal Cord Injury Patient Care Survey	VA Form 10-0515	Spinal Cord Injury Patient Care 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 data collection. All hours are considered a burden increase.

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Annual Cost to Federal Government: $13,850

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: 01/05/2012

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