Conduct the Point-of-Care Research Questionnaire

Forms and Documents

Document Name	Status
OMB response Finalcw.pdf Supplementary Document	2013-11-06
POCR Final budget 4-12-12[1].pdf Supplementary Document	2013-11-06
Theory of Planned Behavaior Manual-Francis[2].pdf Supplementary Document	2013-11-06
IRB POCR survey protocol.pdf Supplementary Document	2013-11-06
Patient Survey REDCap Screen Shots.docx Supplementary Document	2013-09-16
FINAL report POCR 2013.docx Supplementary Document	2013-09-16
National patient letter.docx Supplementary Document	2012-11-06
Survey postcard reminder.docx Supplementary Document	2012-09-06
POC-R_Questionnaire_Justification_A_v3_1162013.docx Supporting Statement A	2013-11-06
POC-R Questionnaire_Justification B_v3_1162013.docx Supporting Statement B	2013-11-06

IC Document Collections

IC ID	Document Title	Status
203111	Point of Care Patient Questionnaire Other-Telephone Survey Script	New

ICR Details

OMB Control No: 2900-0796	ICR Reference No: 201207-2900-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Conduct the Point-of-Care Research Questionnaire
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: 11/08/2013
	Date Received in OIRA: 08/12/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2016	36 Months From Approved
Responses	600	0	0
Time Burden (Hours)	150	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This data collection is authorized under the stated code (38 U.S.C. § 527: US Code - Section 527). This research study is funded by the VA to support one of the VAs 16 transformation initiatives (December 21, 2010 VA Strategic Plan Refresh 2011 – 2015). Initiative #16 specifically addresses Point-of-Care Research. The potential translation impact of Point-of-Care Research (POC-R) within VA is impressive in scope. The outcomes of this study will help with the implementation practices, design of educational materials and the overall approach for POC-R program development within the VA and will be useful to the larger clinical research community. The initial funded proposal was granted on October 1, 2011 for focus groups (Award 1I01CX000691-01).

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Authorizing Statute(s): US Code: 38 USC 527 Name of Law: Data Measurement and Evaluation of VA programs
  

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 26	02/07/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 142	07/24/2013
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
Point of Care Patient Questionnaire	VA Form 10-10069	Research 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	600	0	0	600	0	0
Annual Time Burden (Hours)	150	0	0	150	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 for which all burden hours are considered an increase.

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Annual Cost to Federal Government: $425,000

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: 08/12/2013

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