Information Collection

Evaluation of Veterans Health Administration Mental Health Services

IC 182503 under ICR 200809-2900-012 · OMB 2900-0713.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2900-0713 VA SMI Client Survey.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:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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			2900-0713 VA SMI Client Survey.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	Previously Approved
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.