PACT: VA Form 10-10130 From War To Home - Audience Feedback Questionnaire

Forms and Documents

Document Name	Status
Form 10-10130 From War To Home Audience Feedback Questionnaire VA Form 10-10130 Form and Instruction	New
Supporting Statement S1 10-10130 VISN 4 Audience Feedback Questionnaire 090315.docx Supporting Statement A	2015-09-03

IC Document Collections

IC ID	Document Title	Status
212912	From War To Home Audience Feedback Questionnaire VA Form 10-10130 Form and Instruction	New

ICR Details

OMB Control No: 2900-0839	ICR Reference No: 201409-2900-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No: VHA
Title: PACT: VA Form 10-10130 From War To Home - Audience Feedback Questionnaire
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/09/2015
	Date Received in OIRA: 09/04/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2018	36 Months From Approved
Responses	1,000	0	0
Time Burden (Hours)	83	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This project is being conducted under the auspices of the VISN 4 Demonstration Lab, which was funded by Patient Care Services to assess the Patient Aligned Care Team (PACT) model of care for Veterans. There is considerable interest in and urgency to implement the PACT model – reflecting both a desire to improve health care for Veterans and to sustain the VA's leadership in health care quality. CEPACT aims to contribute to these goals by evaluating the effects of the VA PACT initiative and by testing new, innovative strategies for patient care that can be spread if proven effective. This study builds on a prior photo voice study conducted by the study PI (Dr. True) in collaboration with 29 OEF/OIF Veterans, who used photos and stories to convey their post-deployment experiences, perspectives, and needs. The project aims to enhance PACT implementation by providing education about the needs and experiences of OEF/OIF Veterans that is emotionally resonant and engaging to learners on a visceral level, as well as promoting a greater sense of alignment with VA's mission of providing patient-centered care.

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Authorizing Statute(s): None

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:
	80 FR 4336	01/27/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 46107	08/03/2015
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
From War To Home Audience Feedback Questionnaire VA Form 10-10130	10-10130	VISN 4 Audience Feedback Questionnaire

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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	1,000	0	0	1,000	0	0
Annual Time Burden (Hours)	83	0	0	83	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 therefore all burden is an increase.

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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

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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: 09/04/2015

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