Ethics Consultation Feedback Tool (ECFT)

Forms and Documents

Document Name	Status
Form VA Form 10-10065 Ethics Consultation Feedback Tool Form	Modified
30 Day FRN - Published.pdf Supplementary Document	2018-07-12
60 Day FRN - Published - 2900-0750.pdf Supplementary Document	2018-04-16
10-10065 Ethics Justification 081417.docx Supporting Statement A	2018-07-17

IC Document Collections

IC ID	Document Title	Status
192020	Ethics Consultation Feedback Tool Form	Modified

ICR Details

OMB Control No: 2900-0750	ICR Reference No: 201709-2900-016
Status: Active	Previous ICR Reference No: 201304-2900-006
Agency/Subagency: VA	Agency Tracking No: 2900-0750
Title: Ethics Consultation Feedback Tool (ECFT)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/30/2018
	Date Received in OIRA: 07/17/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2021	36 Months From Approved
Responses	569	0	0
Time Burden (Hours)	47	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Ethics consultation is a service provided in all Veterans Health Administration (VHA) facilities. Ensuring the success of the ethics consultation service requires ongoing evaluation, underscoring systematic assessment of the operation and/or outcomes of a program compared to a set of explicit or implicit standards, as a means of contributing to the continuous improvement of the program. Evaluation is an important strategy to improve the process of ethics consultation (i.e., how ethics consultation is being performed) as well as its outcomes (i.e., how ethics consultation affects participants and the facility.

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Authorizing Statute(s): US Code: 38 USC Part 1, Chapter 5, Sec. 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:
	82 FR 52972	11/15/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 19141	05/01/2018
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
Ethics Consultation Feedback Tool	VA Form 10-10065	Ethics Consultation Feedback Tool

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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	569	0	0	365	0	204
Annual Time Burden (Hours)	47	0	0	30	0	17
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: Actual data 4th quarter FY 16 through 3rd quarter FY 17 indicates that more people are completing the tool which is providing valuable feedback needed to improve ethics consultation services to Veterans, families and staff. In addition, the hour salary rate has increased.

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Annual Cost to Federal Government: $569

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 07/17/2018

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