Information Collection

Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey

IC 200925 under ICR 201107-2900-001 · OMB 2900-0770.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0770 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-0531 Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey	Form
VHA_ORD_Focus Group Moderators Guide_2_2012.doc	Other-Moderator Script
VHA ORD Focus Group Participant Screener 3_2012.doc Telephonic Screening Call	Other-Participant screener script
VA Form 10-0531 Childcare Services Satisfaction Survey Childcare Services Satisfaction Survey 10-0531.DOCX	Form
VA Form 10-0538 Purchased Care Patient Satisfaction Survey Purchased Care Patient Satisfaction Survey_10-0538.docx URL To Be Determined	Form
VA Form 10-0540 Teleretinal Patient Satisfaction Survey TeleRetinal Patient Survey_10-0540.pdf	Form
VA Form 10-0542 Spinal Cord Home Care Survey Spinal Cord Home Care Survey 10-0542.doc	Form
Childcare Generic_Clearance_Submission.docx Childcare Generic_Clearance_Submission	IC Document
Purchased Care Online Survey_Generic Request(v4).docx Purchased Care Online Survey_Generic Request	IC Document
Teleretinal_Generic_Clearance_Submission.docx Teleretinal_Generic_Clearance_Submission	IC Document
Spinal Cord home Care Survey Generic_Request.docx Spinal Cord home Care Survey Generic_Request	IC Document
VHA ORD Generic Clearance_Request__3_7_2012.doc Focus Groups Soliciting feedback on VA Research Communication	IC Document
VA ORD_Informed_Consent_Form (4).docx ORD Informed Consent	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey

Agency IC Tracking Number:

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	VA Form 10-0531	Childcare Services Satisfaction Survey	Childcare Services Satisfaction Survey 10-0531.DOCX		No		Paper Only
Form	VA Form 10-0538	Purchased Care Patient Satisfaction Survey	Purchased Care Patient Satisfaction Survey_10-0538.docx	URL To Be Determined	Yes	Yes	Fillable Fileable
Form	VA Form 10-0540	Teleretinal Patient Satisfaction Survey	TeleRetinal Patient Survey_10-0540.pdf		No		Paper Only
Form	VA Form 10-0542	Spinal Cord Home Care Survey	Spinal Cord Home Care Survey 10-0542.doc		No		Paper Only
Other-Moderator Script			VHA_ORD_Focus Group Moderators Guide_2_2012.doc		No		Paper Only
Other-Participant screener script			VHA ORD Focus Group Participant Screener 3_2012.doc	Telephonic Screening Call	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30,875

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	30,875	30,875
Annual IC Time Burden (Hours)	1,883	1,883
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Childcare Generic_Clearance_Submission	Childcare Generic_Clearance_Submission.docx	01/27/2012
Purchased Care Online Survey_Generic Request	Purchased Care Online Survey_Generic Request(v4).docx	02/17/2012
Teleretinal_Generic_Clearance_Submission	Teleretinal_Generic_Clearance_Submission.docx	01/27/2012
Spinal Cord home Care Survey Generic_Request	Spinal Cord home Care Survey Generic_Request.docx	01/27/2012
Focus Groups Soliciting feedback on VA Research Communication	VHA ORD Generic Clearance_Request__3_7_2012.doc	03/07/2012
ORD Informed Consent	VA ORD_Informed_Consent_Form (4).docx	02/27/2012

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