MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form VA Form 10-211003 MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey Form
VA Form 10-211003 MSCoE Patient Survey MSCoE Patient Survey 10-211003.pdf To Be Determined Form
VA Form 10-211004 PROJECT ARCH (Access Received Closer to Home) Non-Partic Project ARCH Non-Participant Survey 10-211004.pdf Form
VA Form 10-211005 Patient Survey: Waiting Room Television Video Patient Ed WaitRoom Televison Ed_Survey 10-211005.pdf Form
Generic Request_ MSCoE Patient Survey.docx Multiple Sclerosis Center of Excellence (MSCoE) Outpatient Clinic IC Document
Generic Request ProjectARCH_NonPPA_Survey.docx Project ARCH Non-Participating Veterans Survey IC Document
Generic_Request_Wait Room Televison Survey.docx Patient Survey: Waiting Room Television Video Patient Education IC Document

Information Collection (IC) Details

IC Title:	MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 10-211003	MSCoE Patient Survey	MSCoE Patient Survey 10-211003.pdf	To Be Determined	Yes	Yes	Fillable Fileable
Form	VA Form 10-211004	PROJECT ARCH (Access Received Closer to Home) Non-Participating Veterans Survey	Project ARCH Non-Participant Survey 10-211004.pdf		No		Paper Only
Form	VA Form 10-211005	Patient Survey: Waiting Room Television Video Patient Education	WaitRoom Televison Ed_Survey 10-211005.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,515	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,515	7,515
Annual IC Time Burden (Hours)	1,866	1,866
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Multiple Sclerosis Center of Excellence (MSCoE) Outpatient Clinic	Generic Request_ MSCoE Patient Survey.docx	06/16/2013
Project ARCH Non-Participating Veterans Survey	Generic Request ProjectARCH_NonPPA_Survey.docx	06/16/2013
Patient Survey: Waiting Room Television Video Patient Education	Generic_Request_Wait Room Televison Survey.docx	06/16/2013

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