Survey of Veteran Enrollees -Quality and Efficiency of VA Health Care

Forms and Documents

Document Name	Status
Form VA Form 10-21088 Survey of Veteran Enrollees Quality and Efficiency of VA Health Care Form and Instruction	New
VA Memo.doc Supplementary Document	2009-03-27
VA Form 10-21088 justification.doc Supporting Statement A	2008-10-23

IC Document Collections

IC ID	Document Title	Status
185562	Survey of Veteran Enrollees Quality and Efficiency of VA Health Care Form and Instruction	New

ICR Details

OMB Control No: 2900-0725	ICR Reference No: 200807-2900-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Survey of Veteran Enrollees -Quality and Efficiency of VA Health Care
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: Approved with change	Conclusion Date: 03/30/2009
	Date Received in OIRA: 10/23/2008
Terms of Clearance: Approved consistent with changes outlined in VA memo submitted to OMB.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2012	36 Months From Approved
Responses	80,080	0	0
Time Burden (Hours)	18,133	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: By way of Presidential Executive Order 13410 (08/22/06), Section 1,

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Authorizing Statute(s): US Code: 38 USC 527 Name of Law: Evaluation and data collection
   EO: EO 13410 Name/Subject of EO: Help Increase the Transparency of America's Health Care System
  

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:
	73 FR 151	08/05/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 204	10/21/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Survey of Veteran Enrollees Quality and Efficiency of VA Health Care	VA Form 10-21088	Survey of Veteran Enrollees - Quality and Efficiency of VA Health Care

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ICR Summary of Burden

	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	80,080	0	0	80,080	0	0
Annual Time Burden (Hours)	18,133	0	0	18,133	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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 change.

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Annual Cost to Federal Government: $656,740

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

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: 10/23/2008

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