uSPEQ® Consumer Experience Survey (Rehabilitation)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-0467 uSPEQ® Consumer Experience Survey (Rehabilitation)	Form	Unchanged	Available
Emergency Clearance Request uSPEQ® 2900-0752.pdf	Supplementary Document	Uploaded 2016-11-30	Available
uSPEQ Justification A_2900-0752.docx	Supporting Statement A	Uploaded 2017-03-14	Available
uSPEQ Justification B 2900-0752.docx	Supporting Statement B	Uploaded 2017-03-14	Available
Copyright letter.pdf	Supplementary Document	Uploaded 2009-01-27	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
187874	uSPEQ® Consumer Experience Survey (Rehabilitation)	Form	Unchanged

ICR Details

OMB Control No: 2900-0752	ICR Reference No: 201703-2900-002
Status: Historical Active	Previous ICR Reference No: 201611-2900-012
Agency/Subagency: VA	Agency Tracking No:
Title: uSPEQ® Consumer Experience Survey (Rehabilitation)
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: 06/13/2017
	Date Received in OIRA: 03/21/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved	06/30/2017
Responses	384,000	0	384,000
Time Burden (Hours)	32,000	0	32,000
Cost Burden (Dollars)	0	0	0

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Abstract: The uSPEQ® is a confidential, anonymous, and scientifically-tested consumer reporting system that gives persons served a voice in their services. There is a current absence of an existing survey model that is psychometrically sound and nationally benchmarked for survey of consumer experiences in VA rehabilitation programs. VA rehabilitation programs are committed to adopting the uSPEQ® survey to assess outcome measures related to patient perceptions of and perspectives regarding rehabilitation experiences. VA recognizes that adoption of this survey provides a systems approach and benchmarking capability for patient assessed outcomes of care.

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Authorizing Statute(s): US Code: 38 USC Chapter 17 Name of Law: Hospital, Nursing Home, Domiciliary, and Medical Care
  

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:
	81 FR 86073	11/29/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 13057	03/08/2017
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
uSPEQ® Consumer Experience Survey (Rehabilitation)	VA Form 10-0467	uSPEQ Consumer Experience Survey (Rehabilitation)

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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	384,000	384,000	0	0	0	0
Annual Time Burden (Hours)	32,000	32,000	0	0	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:

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Annual Cost to Federal Government: $960,000

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: 03/21/2017

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