Health Eligibility Center (HEC) New Enrollee Survey

Forms and Documents

Document Name	Status
Form VA Form 10-0479 HEC New Enrollee Survey Form	Unchanged
Justification_B__New_Enrollee_Survey.doc Supporting Statement B	2010-11-19
Justification_A_New_Enrollee_Survey.doc Supporting Statement A	2010-11-19
HEC Enrollee Survey cover letter.doc Supplementary Document	2010-11-23

IC Document Collections

IC ID	Document Title	Status
191196	HEC New Enrollee Survey Form	Unchanged

ICR Details

OMB Control No: 2900-0758	ICR Reference No: 201008-2900-001
Status: Historical Active	Previous ICR Reference No: 200911-2900-005
Agency/Subagency: VA	Agency Tracking No:
Title: Health Eligibility Center (HEC) New Enrollee Survey
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 without change	Conclusion Date: 12/05/2010
	Date Received in OIRA: 08/26/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2013	36 Months From Approved
Responses	1,614	0	0
Time Burden (Hours)	153	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The HEC seeks approval for this information collection that will allow Veterans an opportunity to provide anonymous feedback on how well the HEC enrolls new Veterans. HEC will use this feedback to improve the enrollment processes. VA will use the information gathered to determine where and to what extent services are satisfactory, and where and to what extent they are in need of improvement. The information may lead to policy changes which improve Veteran satisfaction with VA Healthcare benefits.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

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:
	74 FR 218	11/13/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 13	01/21/2010
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
HEC New Enrollee Survey	VA Form 10-0479	Health Eligibility Center (HEC) New Enrollee 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	1,614	0	0	1,614	0	0
Annual Time Burden (Hours)	153	0	0	153	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, so all burden hours are considered an increase.

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Annual Cost to Federal Government: $3,500

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: 08/26/2010

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