Evaluation of Patient and Provider Satisfaction with Mental Health-Clinical Pharmacy Specialists in Outpatient Mental Health Clinics at the Madison VA

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
30 Day FRN - Published.pdf	Supplementary Document	Uploaded 2018-09-19	Repair queued
60 Day FRN - Published.pdf	Supplementary Document	Uploaded 2018-07-12	Repair queued
Justification A - Madison VAMC_MH-CPS_Updated FRN_071218.docx	Supporting Statement A	Uploaded 2018-07-12	Repair queued
Justification B - Madison VAMC_MH CPS.doc	Supporting Statement B	Uploaded 2018-01-17	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
229685	Provider Satisfaction with Mental Health-Clinical Pharmacy Specialists at the Madison VA	Other-Questionnaire	New
229684	Patient Satisfaction with Mental Health-Clinical Pharmacy Specialists at the Madison VA	Other-Questionnaire	New

ICR Details

OMB Control No:	ICR Reference No: 201801-2900-001
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Evaluation of Patient and Provider Satisfaction with Mental Health-Clinical Pharmacy Specialists in Outpatient Mental Health Clinics at the Madison VA
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OIRA Conclusion Action: Withdrawn	Conclusion Date: 05/06/2019
	Date Received in OIRA: 10/22/2018
Terms of Clearance:

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: The information collected in this survey will be utilized by the Mental Health Clinical Pharmacy Specialists (MH-CPS) in the Madison VA Mental Health Clinic to assess patient satisfaction with care provided by MH-CPS. Results will be used to identify areas for improvement.

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Authorizing Statute(s): None

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:
	83 FR 4561	01/31/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 34927	07/23/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Patient Satisfaction with Mental Health-Clinical Pharmacy Specialists at the Madison VA
Provider Satisfaction with Mental Health-Clinical Pharmacy Specialists at the Madison VA

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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 collection and all burden hours are considered a program increase.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 10/22/2018

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