Care Coordination Home Telehealth (CCHT) Patient Satisfaction Survey

Forms and Documents

Document Name	Status
Form 10-0341 Care Coordination Home Telehealth Patient Satisfaction Survey Form and Instruction	Modified
SENT_VE_Non_Substantial_Change_White Paper 12 28 15 _ Final - 1.4.16.docx Justification for No Material/Nonsubstantive Change	2016-01-04
White Paper Revisions to Form 10-0481 CCHT_20140314.docx Supplementary Document	2014-03-14
Core-CCT_Conditions of Participants.doc Supplementary Document	2013-08-23
CCHT_Justification_B_2900-0766.doc Supporting Statement B	2013-08-23
CCHT Justification A 2900-0766_20140305 (CR 3 11 14v2)_GO_20140314.doc Supporting Statement A	2014-03-14

IC Document Collections

IC ID	Document Title	Status
191713	Care Coordination Home Telehealth Patient Satisfaction Survey Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0766	ICR Reference No: 201512-2900-010
Status: Historical Active	Previous ICR Reference No: 201308-2900-016
Agency/Subagency: VA	Agency Tracking No:
Title: Care Coordination Home Telehealth (CCHT) Patient Satisfaction Survey
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/04/2016
	Date Received in OIRA: 01/04/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2017	05/31/2017	05/31/2017
Responses	65,600	0	65,600
Time Burden (Hours)	1,640	0	1,640
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 38 USC Part 1, Chapter 5, Section 527 Name of Law: Veterans Benefits
  

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:
	78 FR 168	08/29/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 76193	12/16/2013
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Care Coordination Home Telehealth Patient Satisfaction Survey	10-0341	VHA Telehealth Services HT Patient Satisfaction Survey

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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	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $645

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 01/04/2016

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