Bereaved Family Member Satisfaction Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-21081(N Bereaved Family Member Satisfaction Survey	Form	Modified	Available
2900-0701_justification_Part_B1 FY12_FINAL 2-10-2012.doc	Supporting Statement B	Uploaded 2012-02-15	Available
2900-0701_justification_Part_A (v2)_5-8-12.doc	Supporting Statement A	Uploaded 2012-05-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
178992	Bereaved Family Member Satisfaction Survey	Form	Modified

ICR Details

OMB Control No: 2900-0701	ICR Reference No: 201202-2900-006
Status: Historical Active	Previous ICR Reference No: 200812-2900-011
Agency/Subagency: VA	Agency Tracking No: 2900-0701
Title: Bereaved Family Member Satisfaction Survey
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/29/2012
	Date Received in OIRA: 05/15/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	36 Months From Approved	06/30/2012
Responses	11,000	0	9,900
Time Burden (Hours)	1,833	0	1,650
Cost Burden (Dollars)	0	0	0

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Abstract: The death rate for veterans will continue to grow as the number of veterans 85 years of age and older will triple between the year 2000 and 2010. This peak in veteran deaths combined with the VA’s strategic plan to focus on patient/family centered care has illuminated the need for assessing family member satisfaction with the end of life care provided in the VA. The purpose of this survey is to determine the validity and feasibility of implementing the survey instrument and the effectiveness of reporting these results through the use of a centralized data collection process on a secure web site.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
   US Code: 38 USC Part I 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:
	77 FR 39	02/28/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 91	05/10/2012
Did the Agency receive public comments on this ICR? Yes

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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
Bereaved Family Member Satisfaction Survey	VA Form 10-21081(NR)	Bereaved Family Member Satisfaction Survey_Administered by Facility Staff

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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	11,000	9,900	0	1,100	0	0
Annual Time Burden (Hours)	1,833	1,650	0	183	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The burden increase reflects an increase in the use of the survey by all Veterans Integrated Service Networks (VISNs) throughout VA.

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Annual Cost to Federal Government: $1,000,000

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: 05/15/2012

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