OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Care Coordination Home Telehealth (CCHT) Patient Satisfaction Survey

ICR 201001-2900-003 · OMB 2900-0766 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
CCT Core Conditions of Participation 3-10.docm Supplementary Document Uploaded 2010-08-18 Available
CCHT_justification_B_(V3)1.doc Supporting Statement B Uploaded 2010-08-18 Available
CCHT justification A (V4).doc Supporting Statement A Uploaded 2010-03-16 Available
IC Document Collections
IC IDCollectionTypeStatusForm
191713 Care Coordination Home Telehealth Patient Satisfaction Survey Other-Electronic Survey Questions New
ICR Details
2900-0766 201001-2900-003
Historical Active
VA
Care Coordination Home Telehealth (CCHT) Patient Satisfaction Survey
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 03/16/2011
Retrieve Notice of Action (NOA) 03/31/2010
Approved consistent with revisions submitted by VA and included in the public docket.
  Inventory as of this Action Requested Previously Approved
03/31/2014 36 Months From Approved
65,600 0 0
1,640 0 0
0 0 0
The CCHT satisfaction survey will capture current patients’ perspectives on satisfaction with specific aspects of the program and equipment through an automated method. The survey will be delivered electronically to patients enrolled in the CCHT Program via a messaging device located in the patient’s home. These devices will provide questions to enrolled patients on a small screen and in some cases, the questions are electronically spoken to visually impaired patients through Interactive Voice Response. The patient will select the appropriate answer using either buttons or a touch screen application. Patient satisfaction responses will be captured electronically and reported.
US Code: 38 USC Part 1, Chapter 5, Section 527 Name of Law: Veterans Benefits
  
None
Not associated with rulemaking
  75 FR 10 01/15/2010
75 FR 59 03/29/2010
No
1
IC Title Form No. Form Name
Care Coordination Home Telehealth Patient Satisfaction Survey
  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 65,600 0 0 65,600 0 0
Annual Time Burden (Hours) 1,640 0 0 1,640 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new collection and all burden hours are considered a program increase
$645
Yes Part B of Supporting Statement
No
No
No
No
Uncollected
Denise McLamb 202-565-8374 [email protected]
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
03/31/2010