Information Collection

Access to Care Survey Questionnaire

IC 207889 under ICR 201307-2900-011 · OMB 2900-0824.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-10067 Access to Care Survey Questionnaire	Form and Instruction
VA Form 10-10067 Access to Care Survey Questionnaire VA form 10-10067_Access to Care Questionnaire(2-27-14) (v3)-OMB Comments HM(3).docx	Form and Instruction

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
Form and Instruction	VA Form 10-10067	Access to Care Survey Questionnaire	VA form 10-10067_Access to Care Questionnaire(2-27-14) (v3)-OMB Comments HM(3).docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

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	20	20
Annual IC Time Burden (Hours)	10	10
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.