Information Collection

HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey

IC 209895 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⚠️ Notice: This information collection may be referencing outdated material.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 10-211014 HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey	Form
VA Form 10-211014 Home Based Primary Care Survey LawtonCBOC HB Primary Care Survey_10-211014.pdf	Form
VA Form 10-211013 Non-VA-Purchased Care Veteran Survey VA Form 10-211013_Non-VA PC Survey_10-2013.pdf URL to be determined	Form
VA Form 10-211011 Dental Insurance Program Survey VA Form 10-211011 Dental Insurance Survey 10-13.pdf URL to be determined	Form
VA Form 10-211016 Tele-Dermatology Imaging Patient Satisfaction Survey Tele-Dermatology Satisfaction Survey 10-211016.pdf TeleForm software will be used: URL TBD	Form
Generic Submission_Home Based Primary Care.docx Home Based Primary Care Patient Satisfaction	IC Document
HBPC Survey Letter OKC.doc HBPC Survey Letter OKC/Lawton	IC Document
VA Generic_Request_PurchasedCare Veteran Survey (v5)11-13.docx NonVA Purchased Care Veteran Survey	IC Document
Generic_Submission_Dental Insurance Survey.docx Dental Insurance Survey	IC Document
Generic Request TeleDermatology Survey 01-28-14 (v2).docx Teledermatology Imaging Patient Satisfaction Survey	IC Document

IC Title:

HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient 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 10-211014	Home Based Primary Care Survey	LawtonCBOC HB Primary Care Survey_10-211014.pdf		No		Paper Only
Form	VA Form 10-211013	Non-VA-Purchased Care Veteran Survey	VA Form 10-211013_Non-VA PC Survey_10-2013.pdf	URL to be determined	Yes	Yes	Fillable Fileable
Form	VA Form 10-211011	Dental Insurance Program Survey	VA Form 10-211011 Dental Insurance Survey 10-13.pdf	URL to be determined	Yes	Yes	Fillable Fileable
Form	VA Form 10-211016	Tele-Dermatology Imaging Patient Satisfaction Survey	Tele-Dermatology Satisfaction Survey 10-211016.pdf	TeleForm software will be used: URL TBD	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14,320

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	14,320	14,320
Annual IC Time Burden (Hours)	1,388	1,388
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Home Based Primary Care Patient Satisfaction	Generic Submission_Home Based Primary Care.docx	12/30/2013
HBPC Survey Letter OKC/Lawton	HBPC Survey Letter OKC.doc	12/30/2013
NonVA Purchased Care Veteran Survey	VA Generic_Request_PurchasedCare Veteran Survey (v5)11-13.docx	12/30/2013
Dental Insurance Survey	Generic_Submission_Dental Insurance Survey.docx	12/30/2013
Teledermatology Imaging Patient Satisfaction Survey	Generic Request TeleDermatology Survey 01-28-14 (v2).docx	01/29/2014

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