Information Collection

Evaluation of Veterans Health Administration Mental Health Services

IC 182503 under ICR 200710-2900-008 · OMB 2900-0713.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0713 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
VA SMI Client Survey_OMB_Dec07.doc	Other-survey
background info.doc Background info.doc	IC Document
VA SMI Advance Letter_OMB.doc Advance Letter	IC Document
VA SMI Brochure_OMB.doc info brochure	IC Document
VA SMI Emergency Proc_OMB.doc emergency procedures	IC Document
VMHSE Incident Report Form_OMB_rev12-7-07.doc Incident Report	IC Document
VMHSE Phone Intro Script_OMB_rev12-7-07.doc Phone Script	IC Document
VMHSE Phone Update Letter Enclosure_OMB_rev12-7-07.doc Update Letter	IC Document
VMHSE Reminder Letter_OMB_rev12-7-07.doc Reminder Letter	IC Document
VMHSE SHORT BLESSED SCALE EXAM _OMB.doc Blessed Scale Exam	IC Document
VMHSE Thank You Letter_OMB_rev12-7-07.doc Thank you Letter	IC Document
VMHSE Interviewer FAQs_OMB_12-7-07.doc Interviewer FAQs	IC Document

IC Title:

Evaluation of Veterans Health Administration Mental Health Services

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 1.15

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-survey			VA SMI Client Survey_OMB_Dec07.doc		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8,218

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	8,218	8,218
Annual IC Time Burden (Hours)	4,109	4,109
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Background info.doc	background info.doc	10/29/2007
Advance Letter	VA SMI Advance Letter_OMB.doc	10/29/2007
info brochure	VA SMI Brochure_OMB.doc	10/29/2007
emergency procedures	VA SMI Emergency Proc_OMB.doc	10/29/2007
Incident Report	VMHSE Incident Report Form_OMB_rev12-7-07.doc	12/18/2007
Phone Script	VMHSE Phone Intro Script_OMB_rev12-7-07.doc	12/18/2007
Update Letter	VMHSE Phone Update Letter Enclosure_OMB_rev12-7-07.doc	12/18/2007
Reminder Letter	VMHSE Reminder Letter_OMB_rev12-7-07.doc	12/18/2007
Blessed Scale Exam	VMHSE SHORT BLESSED SCALE EXAM _OMB.doc	12/18/2007
Thank you Letter	VMHSE Thank You Letter_OMB_rev12-7-07.doc	12/18/2007
Interviewer FAQs	VMHSE Interviewer FAQs_OMB_12-7-07.doc	12/18/2007

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