Access to Care Survey Questionnaire and Interview Guide (Dialysis)

Forms and Documents

Document Name	Status
Form VA Form 10-10067 Access to Care Survey Questionnaire Form and Instruction	New
Justification B - OMB Comments-VA Response (8-26-14).docx Supporting Statement B	2014-10-29
Justification A _Access to Care_Survey- Interview (2-27-14) - response .docx Supporting Statement A	2014-10-29

IC Document Collections

IC ID	Document Title	Status
210546	Access to Care Interview Other-Interview guide	New
207889	Access to Care Survey Questionnaire Form and Instruction	New

ICR Details

OMB Control No: 2900-0824	ICR Reference No: 201307-2900-011
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Access to Care Survey Questionnaire and Interview Guide (Dialysis)
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: 11/05/2014
	Date Received in OIRA: 03/13/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2017	36 Months From Approved
Responses	40	0	0
Time Burden (Hours)	25	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: 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.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 51276	08/20/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 69748	11/20/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 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

---

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	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

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 data collection. All burden hours are considered an increase.

---

Annual Cost to Federal Government: $0

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(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: 03/13/2014

---