Customer Satisfaction Survey for Nutrition and Food Service

Forms and Documents

Document Name	Status
Form VA Form 10-5387 Customer Satisfaction Survey for Nutrition and Food Service Form	Modified
2900-0227 justification updated version.doc Supporting Statement A	2009-10-05

IC Document Collections

IC ID	Document Title	Status
44124	Customer Satisfaction Survey for Nutrition and Food Service Form	Modified

ICR Details

OMB Control No: 2900-0227	ICR Reference No: 200907-2900-005
Status: Historical Active	Previous ICR Reference No: 200604-2900-008
Agency/Subagency: VA	Agency Tracking No: 2900-0227
Title: Customer Satisfaction Survey for Nutrition and Food Service
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/18/2009
	Date Received in OIRA: 10/05/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2012	36 Months From Approved	11/30/2009
Responses	125,600	0	520,400
Time Burden (Hours)	4,187	0	199,907
Cost Burden (Dollars)	0	0	0

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Abstract: VA can achieve significant savings through advanced food preparation and advanced food delivery systems. To determine the level of patient satisfaction and quality of services provided, the survey is needed to be performed at the medical centers. The on-going quarterly survey is essential to providing Nutrition and Food Service personnel with reliable, timely information on the quality of food and nutritional services provided to veteran patients.

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Authorizing Statute(s): US Code: 38 USC Section 219 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:
	74 FR 144	07/29/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 190	10/02/2009
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
Customer Satisfaction Survey for Nutrition and Food Service	VA Form 10-5387	Customer Satisfaction Survey for Nutrition and Food Service

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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	125,600	520,400	0	0	-394,800	0
Annual Time Burden (Hours)	4,187	199,907	0	0	-195,720	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: The following VA forms were collections under 2900-0227 and are now being collected under 2900-0712 (Nation-wide Customer Satisfaction Surveys), which attributes to the decrease in burden hours for this collection: VA Form 10-1465-1, Survey of Healthcare Experiences of Patients Recently Discharged (Inpatient) – 37,500 VA Form 10-1465-3, Survey of Healthcare Experiences Patient’s Ambulatory Care(Outpatient) – 153,300 VA Form 10-0142B, About Your VA Prosthetics Care and Service (Prosthetic) - 600 VA Form 10-1465-9, About Your Home Based Primary Care (HBPC) – 4,320

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Annual Cost to Federal Government: $72,597

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

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: 10/05/2009

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