Information Collection

Point of Care Patient Questionnaire

IC 203111 under ICR 201207-2900-003 · OMB 2900-0796.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
POC Patient Phone Script.docx	Other-Telephone Survey Script
VA Form 10-10069 Research Questionnaire POC Research Questionnaire 10-10069_9-2013.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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
Other-Telephone Survey Script			POC Patient Phone Script.docx	N/A	No		Paper Only
Form	VA Form 10-10069	Research Questionnaire	POC Research Questionnaire 10-10069_9-2013.pdf	TBD	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 600

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	600	600
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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