OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Access to Care Survey Questionnaire and Interview Guide (Dialysis)

ICR 201307-2900-011 · OMB 2900-0824 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 10-10067 Access to Care Survey Questionnaire Form and Instruction New Available
Justification B - OMB Comments-VA Response (8-26-14).docx Supporting Statement B Uploaded 2014-10-29 Available
Justification A _Access to Care_Survey- Interview (2-27-14) - response .docx Supporting Statement A Uploaded 2014-10-29 Available
IC Document Collections
IC IDCollectionTypeStatusForm
210546 Access to Care Interview Other-Interview guide New
207889 Access to Care Survey Questionnaire Form and Instruction New
ICR Details
2900-0824 201307-2900-011
Historical Active
VA
Access to Care Survey Questionnaire and Interview Guide (Dialysis)
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 11/05/2014
Retrieve Notice of Action (NOA) 03/13/2014
  Inventory as of this Action Requested Previously Approved
11/30/2017 36 Months From Approved
40 0 0
25 0 0
0 0 0
A principal goal of the Dialysis Pilot program for the treatment of End Stage Renal Disease (ESRD) is to improve access to dialysis care for Veterans. This Access to Care IC will include a consideration of the access to care dimensions (e.g., travel distance), patient demographic, and socio-economic characteristics associated with Veterans' use of the pilot VA-operated free-standing outpatient dialysis clinics. This IC will provide an independent assessment and analysis of barriers and facilitators that Veterans may experience while accessing the outpatient dialysis clinics.
None
None
Not associated with rulemaking
  78 FR 51276 08/20/2013
78 FR 69748 11/20/2013
No
2
IC Title Form No. Form Name
Access to Care Survey Questionnaire VA Form 10-10067 Access to Care Survey Questionnaire
Access to Care Interview
  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 40 0 0 40 0 0
Annual Time Burden (Hours) 25 0 0 25 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new data collection. All burden hours are considered an increase.
$0
No
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.
03/13/2014