Information Collection

Health Insurance and Key Driver Modules - Survey of Veteran Enrollees' Health and Reliance Upon VA

IC 45604 under ICR 200610-2900-003 · OMB 2900-0693.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-21034k Key Drivers Module 2 Health Insurance and Key Driver Modules - Survey of Veteran Enrollees' Health and Reliance Upon VA	Form
Form VA Form 10-21034j Health Insurance Module 1 Health Insurance and Key Driver Modules - Survey of Veteran Enrollees' Health and Reliance Upon VA	Form
Form VA Form 10-21034j Cover Sheet for Health Insurance Module 1 Health Insurance and Key Driver Modules - Survey of Veteran Enrollees' Health and Reliance Upon VA	Form
Form VA Form 10-21034k Cover Sheet for Key Drivers Module 2 Health Insurance and Key Driver Modules - Survey of Veteran Enrollees' Health and Reliance Upon VA	Form
VA Form 10-21034j Health Insurance Module 1 2900-New Cover for 10-21034j module 1.pdf	Form
VA Form 10-21034j Cover Sheet for Health Insurance Module 1 2900-New 10-21034j module 1.xls	Form
VA Form 10-21034k Cover Sheet for Key Drivers Module 2 2900-New Cover for 10-21034k module 2 .pdf	Form
VA Form 10-21034k Key Drivers Module 2 2900-New 10-21034k module 2 .xls	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Form	VA Form 10-21034j	No	Paper Only
Form	VA Form 10-21034j	No	Paper Only
Form	VA Form 10-21034k	No	Paper Only
Form	VA Form 10-21034k	No	Paper Only

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 44,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	44,000	44,000
Annual IC Time Burden (Hours)	3,168	3,168
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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