OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Care Coordination Home Telehealth (CCHT) Patient Satisfaction Survey

ICR 201512-2900-010 · OMB 2900-0766 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 10-0341 Care Coordination Home Telehealth Patient Satisfaction Survey Form and Instruction Modified Available
SENT_VE_Non_Substantial_Change_White Paper 12 28 15 _ Final - 1.4.16.docx Justification for No Material/Nonsubstantive Change Uploaded 2016-01-04 Available
White Paper Revisions to Form 10-0481 CCHT_20140314.docx Supplementary Document Uploaded 2014-03-14 Repair queued
Core-CCT_Conditions of Participants.doc Supplementary Document Uploaded 2013-08-23 Available
CCHT_Justification_B_2900-0766.doc Supporting Statement B Uploaded 2013-08-23 Available
CCHT Justification A 2900-0766_20140305 (CR 3 11 14v2)_GO_20140314.doc Supporting Statement A Uploaded 2014-03-14 Available
IC Document Collections
IC IDCollectionTypeStatusForm
191713 Care Coordination Home Telehealth Patient Satisfaction Survey Form and Instruction Modified
ICR Details
2900-0766 201512-2900-010
Historical Active 201308-2900-016
VA
Care Coordination Home Telehealth (CCHT) Patient Satisfaction Survey
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved with change 01/04/2016
Retrieve Notice of Action (NOA) 01/04/2016
  Inventory as of this Action Requested Previously Approved
05/31/2017 05/31/2017 05/31/2017
65,600 0 65,600
1,640 0 1,640
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
  78 FR 168 08/29/2013
78 FR 76193 12/16/2013
Yes
1
IC Title Form No. Form Name
Care Coordination Home Telehealth Patient Satisfaction Survey 10-0341 VHA Telehealth Services HT 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 65,600 0 0 0 0
Annual Time Burden (Hours) 1,640 1,640 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$645
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.
01/04/2016