Outpatient Pharmacy Customer Satisfaction 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⚠️ Notice: This information collection may be referencing outdated material.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 Fform 10-211006 Outpatient Pharmacy Customer Satisfaction Survey Form
VA Fform 10-211006 Outpatient Pharmacy Customer Satisfaction Survey Pharmacy Outpatient Satisfaction Survey__Form 10-211006NR.pdf Form
Generic Submission__Outpatient Pharmacy Satisfaction Survey 2013.docx Outpatient: Pharmacy Satisfaction Survey IC Document

Information Collection (IC) Details

IC Title:	Outpatient Pharmacy Customer Satisfaction Survey	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320.9

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Fform 10-211006NR	Outpatient Pharmacy Customer Satisfaction Survey	Pharmacy Outpatient Satisfaction Survey__Form 10-211006NR.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	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	50	50
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Outpatient: Pharmacy Satisfaction Survey	Generic Submission__Outpatient Pharmacy Satisfaction Survey 2013.docx	08/13/2013

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