Information Collection

Survey of Healthcare Experiences of Patients, Dental Patient Satisfaction Survey

IC 192326 under ICR 201003-2900-014 · OMB 2900-0764.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0764 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-0503 Survey of Healthcare Experiences of Patients, Dental Patient Satisfaction Survey	Form and Instruction
VA Form 10-0503 Survey of Healthcare Experiences of Patients, Dental Pat Dental Survey 10-0503 final.pdf To Be Determined by Contractor	Form and Instruction

IC Title:

Survey of Healthcare Experiences of Patients, Dental Patient Satisfaction Survey

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 10-0503	Survey of Healthcare Experiences of Patients, Dental Patient Satisfaction Survey	Dental Survey 10-0503 final.pdf	To Be Determined by Contractor	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 36,585

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	36,585	36,585
Annual IC Time Burden (Hours)	9,146	9,146
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.