Information Collection

VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction

IC 203264 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⚠️ Notice: This information collection may be referencing outdated material.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 10-0551 VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction	Form
VCS Focus Group Training Script.doc	Other-Training Script
Script forMental Health Satisfaction Survey final[1].doc	Other-Information Script
VA Form 10-0551 VCS Patriot Store and VCS Patriot Cafe Customer Satisfac VCS Patriot Store_Cafe Survey Form 10-0551.doc	Form
VA form 10-0552 Patient Experience of Care Survey Patient Experiences Survey_10-0552.doc	Form
VA form 10-0553 Dental Service Customer Satisfaction Survey 10-0553_Dental_Satisfaction_Survey_(English_Version)10-20121.docx	Form
VA Form 10-0553S Dental Satisfaction Survey (Spanish version) 10-0553S_Encuesta Satisfaccion de Pacientes Dental (2).docx	Form
VA Form 10-0554 Office of Mental Health Veteran Satisfaction Survey 10-0554_OMH Veteran Survey_July 2012_final.doc	Form
Generic_Request VCS Surveys[1].docx Generic_Request VCS Surveys	IC Document
Generic Submission-VCS Focus Groups.docx Generic Submission-VCS Focus Group	IC Document
Generic_Submission_Request EM Patient Survey[1].docx Generic_Submission_Request EM Patient Survey	IC Document
Dental Survey Generic_Submission_Template (3)[1].docx Dental Survey Generic Clearance Submission	IC Document
Mental_Health_Generic_Clearance_Submission_final (2).docx Mental Health Veteran Satisfaction Generic_Request	IC Document

IC Title:

VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction

Agency IC Tracking Number:

2900-0770

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 10-0551	VCS Patriot Store and VCS Patriot Cafe Customer Satisfaction Survey	VCS Patriot Store_Cafe Survey Form 10-0551.doc		No		Paper Only
Other-Training Script			VCS Focus Group Training Script.doc		No		Paper Only
Form	VA form 10-0552	Patient Experience of Care Survey	Patient Experiences Survey_10-0552.doc		No		Paper Only
Form	VA form 10-0553	Dental Service Customer Satisfaction Survey	10-0553_Dental_Satisfaction_Survey_(English_Version)10-20121.docx		No		Paper Only
Form	VA Form 10-0553S	Dental Satisfaction Survey (Spanish version)	10-0553S_Encuesta Satisfaccion de Pacientes Dental (2).docx		No		Paper Only
Form	VA Form 10-0554	Office of Mental Health Veteran Satisfaction Survey	10-0554_OMH Veteran Survey_July 2012_final.doc	TBD	Yes	Yes	Fillable Fileable
Other-Information Script			Script forMental Health Satisfaction Survey final[1].doc	TBD	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11,765

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	11,765	11,765
Annual IC Time Burden (Hours)	2,632	2,632
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic_Request VCS Surveys	Generic_Request VCS Surveys[1].docx	09/24/2012
Generic Submission-VCS Focus Group	Generic Submission-VCS Focus Groups.docx	09/24/2012
Generic_Submission_Request EM Patient Survey	Generic_Submission_Request EM Patient Survey[1].docx	09/24/2012
Dental Survey Generic Clearance Submission	Dental Survey Generic_Submission_Template (3)[1].docx	09/24/2012
Mental Health Veteran Satisfaction Generic_Request	Mental_Health_Generic_Clearance_Submission_final (2).docx	10/05/2012

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