Information Collection

MOVE! Weight Management Program for Veterans, Survey of Patient Experiences

IC 189659 under ICR 200906-2900-015 · OMB 2900-0753.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-0472 MOVE! Weight Management Program for Veterans, Survey of Patient Experiences	Form and Instruction
VA Form 10-0472 MOVE! Weight Management Program for Veterans, Survey of MOVE_Patient_Survey(v3).doc	Form and Instruction

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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	VA Form 10-0472	MOVE! Weight Management Program for Veterans, Survey of Patient Experiences	MOVE_Patient_Survey(v3).doc		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

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	5,000	5,000
Annual IC Time Burden (Hours)	1,250	1,250
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.