OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Patient Satisfaction Survey Michael E. DeBakey Home Care Program

ICR 201211-2900-004 · OMB 2900-0775 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Justification B 2012.doc Supporting Statement B Uploaded 2012-11-06 Available
10-0476 Justification A.docx Supporting Statement A Uploaded 2012-11-06 Available
IC Document Collections
IC IDCollectionTypeStatusForm
194516 Patient Satisfaction Survey, Michael E. DeBakey Home Care Program Other-Telephonic Modified
ICR Details
2900-0775 201211-2900-004
Historical Active 201009-2900-003
VA
Patient Satisfaction Survey Michael E. DeBakey Home Care Program
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 04/09/2013
Retrieve Notice of Action (NOA) 03/05/2013
OMB does not approve this collection. This action is taken to provide VA with an active control number that may be discontinued. VA will discontinue this control number within 1 month of issuance. VA will then submit this collection as a Gen IC under VHA's Fast Track Generic clearance.
  Inventory as of this Action Requested Previously Approved
04/30/2014 36 Months From Approved
100 0 0
17 0 0
0 0 0
Executive Order 12862, Setting Customer Service Standards, calls for the establishment and implementation of customer service standards, and for agencies to "survey customers to determine the kind and quality of services they want and their level of satisfaction with current services". The Michael E. DeBakey Home Care Program Patient Satisfaction tool will allow for patient objective and anonymous feedback. The Patient Satisfaction survey data is collected by telephone because the patients who are on the home care program are the elderly/frail and Spinal Cord Injury. The intent of this survey is to provide feedback to providers and staff regarding patient satisfaction with services provided by or through the DeBakey home care program staff.
EO: EO 12862 Name/Subject of EO: Setting Customer Standards
  
None
Not associated with rulemaking
  77 FR 223 11/19/2012
78 FR 21 01/31/2013
No
1
IC Title Form No. Form Name
Patient Satisfaction Survey, Michael E. DeBakey Home Care Program
  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 100 0 0 0 0 100
Annual Time Burden (Hours) 17 0 0 0 0 17
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$450
Yes Part B of Supporting Statement
No
No
No
No
Uncollected
Crystal Rennie 202 632-7492 [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.
03/05/2013