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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-1500209(WS) VCP Provider Survey	Form and Instruction	New	Available
Form 10-1500210(WS) VACC Provider Survey	Form and Instruction	New	Available
Form 10-1500199(WS) MySurvey	Form and Instruction	New	Available
Form 10-0476 Michael E. DeBakey Home Care Program	Form and Instruction	New	Available
Form 10-0516 NCL Patient Satisfaction Questionnaire	Form and Instruction	New	Available
Form 10-0481a VA Telehealth Patient Survey	Form and Instruction	New	Available
Form 10-1500196(WS) DMC Survey	Form and Instruction	New	Available
Form 10-1500197(WS) CSPCC Study Chairperson and NSC Survey	Form	New	Available
Form 10-1500188(WS) VA External Communication Conjoint Questionnaire	Form and Instruction	New	Available
Form VA Form 10-10167 Customer Satisfaction Survey on VA Research Communication, VA Research Currents	Form and Instruction	New	Available
Form VA Form 10-10164 VISN 20 Cancer Care Survey	Form and Instruction	New	Available
Form 10-10172 Watson's Caritas Patient Survey	Form and Instruction	New	Available
Form 10-10171 VPS Survey Questions	Form and Instruction	New	Available
Form 10-10170 PIM Stakeholder Interview	Form and Instruction	New	Available
Form 10-10169 PIM Patient INterview Guide	Form and Instruction	New	Available
Form 10-10168 PIM Patient Letter	Form and Instruction	New	Available
Form 10-0552 Patient Experience of Care Survey	Form and Instruction	New	Available
Form 10-0457 VLER Program Survey	Form and Instruction	New	Available
Form 10-0455 Nationwide Dialysis Program Survey	Form and Instruction	New	Available
Form 10-0450 Veterans Choice Program Survey	Form and Instruction	New	Available
Form 10-10119 Caregiver Feedback Form	Form and Instruction	New	Available
Form 10-10155 MEC Notification Survey	Form and Instruction	New	Available
Form 10-10114 National Family Caregiver Participant Training Feedback Form	Form and Instruction	New	Available
Form 2900-0770 2014 NVSBE Post-Engagement Survey	Form	New	Available
Form 2900-0770 Senior Leaders Roundtables	Form and Instruction	New	Available
Form 2900-0770 NRT Satisfaction	Form and Instruction	New	Available
Form 2900-0770 Learning Sessions	Form and Instruction	New	Available
Form 2900-0770 Exhibitor Satisfaction	Form and Instruction	New	Available
Form 2900-0770 CVE Booth Satisfaction	Form and Instruction	New	Available
Form 2900-0770 Business Requirement Sessions	Form and Instruction	New	Available
Form 10-10136 Tobacco and Smoking Cessation Survey	Form and Instruction	New	Available
Form 10-10135 Battlecreek Urgent Care Survey	Form and Instruction	New	Available
Form 10-10133 VISN 1 Patient Satisfaction Survey	Form and Instruction	New	Available
Form 10-10131 IOM VA Mental Health Services Evaluation	Form and Instruction	New	Available
Form 10-10130 IOM VA Mental Health Services Evaluation	Form and Instruction	New	Available
Form 10-10128 IOM VA Mental Health Services Evaluation	Form and Instruction	New	Available
Form 10-10144 Voice of the Veteran (VOV) Satisfaction Survey Office of Strategic Integration (OSI) Conjoint Analysis	Form and Instruction	New	Available
Form 10-10136 State Veterans Home Admin Survey	Form and Instruction	New	Available
Form 10-10128 Advanced Education Veteran Survey	Form and Instruction	New	Available
Form 10-10131 Maternity Care Coordination Survey	Form and Instruction	New	Available
Form 10-10132 Extended Hours Evaluation - Users	Form and Instruction	New	Available
Form 10-10129 Extended Hours Evaluation - Non-Users	Form and Instruction	New	Available
Form VA Form 10163 CFM Supplier Satisfaction Survey	Form and Instruction	New	Available
Form 10-10127 Telehealth Master Preceptor	Form and Instruction	New	Available
Form 10-10129 Mental Health Survey	Form and Instruction	New	Available
Form 10-10128 Audiology Hearing Aid Questionaire	Form and Instruction	New	Available
Form 10-0526 Caribean Harvey Survey	Form and Instruction	New	Available
Form 10-10147 VHA OSI Primary Care Survey	Form and Instruction	New	Available
Form 2900-0770 State Veterans Home Patient Satisfaction	Form and Instruction	New	Available
Form 10-10145 SOU-SORCC Patient Survey	Form and Instruction	New	Available
Form 10-10142 Womens Health Research Network	Form and Instruction	New	Available
Form 2900-0770 OSDBU Post-Event Evaluation	Form	New	Available
Form 2900-0770 Awards and ROI-2013 NVSBC	Form	New	Available
Form 2900-0770 Awards and ROI - 2013 NVSBC	Form	New	Available
Form 10-10125 Prosthetics Customer Service Survey	Form and Instruction	New	Available
Form 10-10126 Patient Satisfaction Survey	Form and Instruction	New	Available
Form 10-10123 MH Veteran Survey	Form and Instruction	New	Available
Form 10-10122 HME Vendor Performance Survey	Form and Instruction	New	Available
Form VA Form 10-211014a Oklahoma City VAMC Home Based Primary Care (HBPC) Program	Form	Modified	Available
Form VA Form 10-211015S Spanish version: Survey of Patient Satisfaction at Surgical Services	Form	Modified	Available
Form VA Form 10-211015 Survey of Patient Satisfaction at Surgical Service	Form	Modified	Available
Form VA Form 10-211016 Tele-Dermatology Imaging Patient Satisfaction Survey	Form	Modified	Available
Form VA Form 10-211011 Dental Insurance Program Survey	Form	Modified	Available
Form VA Form 10-211013 Non-VA-Purchased Care Veteran Survey	Form	Modified	Available
Form VA Form 10-211014 Home Based Primary Care Survey	Form	Modified	Available
Form VA Form 10-211004 Project ARCH Non-Participant Survey	Form	Modified	Available
Form VA Form 10-211013 HEC Enrollment Survey	Form	Modified	Available
Form VA Form 10-211010 Survey of Rehabilitation Care Survey	Form	Modified	Available
Form 10-211009 National Patient Centered Community Care Veterans Survey Question	Form	Modified	Available
Form 10-211008 Dental (Ambulatory) Patient Satisfaction Survey	Form	Modified	Available
Form VA Fform 10-211006 Outpatient Pharmacy Customer Satisfaction Survey	Form	Modified	Available
Form VA Form 10-211005 Patient Survey: Waiting Room Television Video Patient Education	Form	Modified	Available
Form VA Form 10-211004 PROJECT ARCH (Access Received Closer to Home) Non-Participating Veterans Survey	Form	Modified	Available
Form VA Form 10-211003 MSCoE Patient Survey	Form	Modified	Available
Form VA Form 10-211002 Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey	Form	Modified	Available
Form VA Form 10-10059 Telephone Customer Service Experience Satisfaction Survey	Form	Modified	Available
Form VA Form 10-211001N Patient Satisfaction Survey_Boston VAMC_Dept. of Ophthamology	Form	Modified	Available
Form VA Form 10-10058 Telephone Care Services Patient Satisfaction Survey	Form	Modified	Available
Form VA Form 10-10063 Patient Satisfaction Survey- Radiation Oncology	Form	Modified	Available
Form VA Form 10-0480 Compensation and Pension Examination Program (CPEP) Veterans Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0476 Michael E. DeBakey Patient Satisfaction Survey	Form and Instruction	Modified	Available
Form VA Form 10-0559 Sodium Dichromate Exposure Exam Feedback Survey	Form	Modified	Available
Form VA Form 10-0499 Building Better Caregivers Satisfaction Survey	Form and Instruction	Modified	Available
Form VA Form 10-0558 Epilepsy Centers of Excellence (ECoE) Patient Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0500 Fraud, Waste and Abuse Complaint Form	Form	Modified	Available
Form VA Form 10-0498 Food and Nutrition Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0496a Phone Apps Focus Group Demographic Questionnaire	Form	Modified	Available
Form VA Form 10-0496 PTSD Coach App Survey	Form	Modified	Available
Form VA Form 10-0497 VA Courtesy Standards - The Golden Rule Approach Veteran Feedback Form	Form	Modified	Available
Form VA Form 10-0495 Understanding PTSD for Family Caregivers: Feedback Survey	Form	Modified	Available
Form VA Form 10-0554 Office of Mental Health Veteran Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0553S Dental Satisfaction Survey (Spanish version)	Form	Modified	Available
Form VA form 10-0553 Dental Service Customer Satisfaction Survey	Form	Modified	Available
Form VA form 10-0552 Patient Experience of Care Survey	Form	Modified	Available
Form VA Form 10-0551 VCS Patriot Store and VCS Patriot Cafe Customer Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0549 Rx Label Feedback	Form	Modified	Available
Form VA Form 10-0550 Psychiatric Patient Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0547 Cardiac Cath Lab Customer Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0548 Community Living Center (CLC) Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0546 Nuerology/Rehabilitation Inpatient Program Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0545 Non-VA Care Coordination Veteran Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0541 Survey of Veterans' Satisfaction with Income Verification	Form	Modified	Available
Form VA Form 10-0520 National Family Caregiver Participant Training Feedback Form	Form	Modified	Available
Form VA Form 10-0515 Spinal Cord Injury Patient Survey	Form	Modified	Available
Form VA Form 10-0542 Spinal Cord Home Care Survey	Form	Modified	Available
Form VA Form 10-0540 Teleretinal Patient Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0538 Purchased Care Patient Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0531 Childcare Services Satisfaction Survey	Form	Modified	Available
Form Article and Volume Office of Public Health Gulf War Newsletter Survey	Form	Modified	Available
Form VA Form 10-0526 The Continuity of Medication Management Patient Survey	Form	Modified	Available
Form VA Form 10-0528 Vendor Application for Fair	Form	Modified	Available
Form VA form 10-0519 Notice Your Nurse	Form	Modified	Available
Form VA Form 10-0527 PVAMC Low Vision Patient Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0522 Project ARCH (Access Received Closer to Home) Patient Satisfaction Survey	Form and Instruction	Modified	Available
Form VA Form 10-0516 Patient Satisfaction Questionnaire: Laboratory P&LMS VA New England Healthcare System	Form	Modified	Available
Form VA Form 10-0481a Clinical Video Telehealth (CVT) Patient Satisfaction Survey	Form	Modified	Available
Form VA Form 10-0517 Veterans Transportation Service (VTS) Questionnaire	Form	Modified	Available
Correction to burden hours for 2900-0770.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2011-07-08	Available
Generic Clearance Submission Template (2).doc	Supplementary Document	Uploaded 2011-06-01	Available
Qualitative Feedback Justification B.docx	Supporting Statement B	Uploaded 2011-02-18	Available
(NCA VBA VHA)-Qualitative_Feedback_Justification A.doc	Supporting Statement A	Uploaded 2014-06-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
227343	Veterans Experience Appointment Schedule Survey (Rev)	Other-E-Survey	New
227225	Voice of the Customer Questionnaire for Pharmacy Choice	Other-Telephone Survey	New
226882	VA Pittsburgh Health Care System Emergency Department Survey	Other-Survey	New
226763	MHV Summative Test	Other-Summative Test	New
226678	VA Pittsburgh Reseach Survey	Other-Research Survey	New
226359	Veterans Experience Appointment Schedule Survey	Other-eSurvey	New
226288	Mental Health - SORCC	Other-Survey	New
226212	VE Feedback Tool: eComment Card	Other-Web: eComment Card	New
226098	Board of Veterans Appeals Hearing Experience Surveys	Other-Web Survey	New
225782	Supplier Perception Survey	Other-Web Survey	New
225627	Veterans Millennium Act Emergency Care Benefit Satisfaction Survey	Other-Survey	New
225430	Veterans Affairs Acquisition 360 Survey	Other-Survey	New
225315	Admission Process Customer Satisfaction Survey - Roseburg VAMC	Other-Survey	New
225033	Congressional Response Team Customer Satisfaction Survey	Other-Survey	New
224796	VCP_VACC Provider Survey	Instruction	New
224796	VCP_VACC Provider Survey	Form and Instruction	New	VCP Provider Survey
224796	VCP_VACC Provider Survey	Form and Instruction	New	VACC Provider Survey
224294	PTSD Consultation Program	Other-Feedback Survey	New
223683	MHICM Consumer Satisfaction Survey	Other-Survey	New
223599	CWT TW Consumers Satisfaction Survey	Other-Survey	New
223598	CWT IT Stakeholders Satisfaction Survey	Other-Survey	New
223597	CWT IT Consumers Satisfaction Survey_1	Other-Survey	New
223588	MFH Veteran Survey	Other-Survey	New
223587	MFH Caregiver Survey	Other-Survey	New
223586	Community Residential Care	Other-Survey	New
223381	VE Access Survey Questions	Other-Email	New
223072	Debt Management Center - Customer Service Experience	Other-Survey	New
223015	Primary Care Satisfaction and Effectiveness Survey	Other-Questionnaire	New
222959	VAR Mobile App Rev_8-2016	Other-Study Plan	New
222462	Survey regarding effectiveness of the GI Bill Feedback System	Other-Survey Instrument	New
222066	Mental Health - SORCC Satisfaction Survey	Instruction	New
221904	Veteran Experience and Satisfaction with the Department of Veterans Affairs Compensation and Pension Claims Examination Survey	Other-Survey	New
221798	Verification Cost of Compliance	Other-Survey	New
221139	VACT Primary Care Patient Satisfaction Questionnaire	Other-Questionnaire	New
220889	HRC Satisfaction Survey	Other-Telephone Script	New
220703	Non-VA Behavioral Health Care	Other-Survey	New
220699	Rehabilitation and Audiology Customer Service Survey	Other-Telephone Script	New
220531	Shared Decision Making	Other-Veteran Telephone Script	New
220440	VAInfoApp	Form and Instruction	New	MySurvey
219472	Veterans Experience Initiative	Form and Instruction	New	Michael E. DeBakey Home Care Program
219472	Veterans Experience Initiative	Form and Instruction	New	NCL Patient Satisfaction Questionnaire
219448	Clinic Based Telehealth Satisfaction Survey	Form and Instruction	New	VA Telehealth Patient Survey
219215	Cooperative Studies Program	Form and Instruction	New	DMC Survey
219215	Cooperative Studies Program	Form	New	CSPCC Study Chairperson and NSC Survey
219166	Veteran Experience and Satisfaction with the Department of Veteran Affairs Compensation and Pension Claims Examination	Other-Exam survey screen shot of url	New
218997	Health Advocate Survey	Other-Survey	New
218928	Telebenefits Satisfaction Survey	Other-	New
218847	Health Advocate Survey	Other-Survey	New
218836	VA Conjoint Survey - External Communication	Form and Instruction	New	VA External Communication Conjoint Questionnaire
218523	Feedback USA Button	Other-Feed Back Button	New
218519	VHA Women Veterans Call Center	Other-Survey Script	New
218510	Customer Satisfaction Survey for Claims Clinics Pilot Program	Other-survey	New
218501	VISN 20 Cancer Care Survey, VA Research Currents	Form and Instruction	New	Customer Satisfaction Survey on VA Research Communication, VA Research Currents
218501	VISN 20 Cancer Care Survey, VA Research Currents	Form and Instruction	New	VISN 20 Cancer Care Survey
217630	CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score	Form and Instruction	New	Watson's Caritas Patient Survey
217630	CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score	Form and Instruction	New	VPS Survey Questions
217630	CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score	Form and Instruction	New	PIM Stakeholder Interview
217630	CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score	Form and Instruction	New	PIM Patient INterview Guide
217630	CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score	Form and Instruction	New	PIM Patient Letter
216363	NAC Customer Response Survey	Other-Web Based	New
215611	Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care	Form and Instruction	New	Patient Experience of Care Survey
215611	Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care	Form and Instruction	New	VLER Program Survey
215611	Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care	Form and Instruction	New	Nationwide Dialysis Program Survey
215611	Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care	Form and Instruction	New	Veterans Choice Program Survey
214681	MHV Website Redesign, National Family Caregiver Survey, MEC Notification Survey	Form and Instruction	New	Caregiver Feedback Form
214681	MHV Website Redesign, National Family Caregiver Survey, MEC Notification Survey	Form and Instruction	New	MEC Notification Survey
214681	MHV Website Redesign, National Family Caregiver Survey, MEC Notification Survey	Form and Instruction	New	National Family Caregiver Participant Training Feedback Form
214097	2014 NVSBE Post-Engagement	Form	New	2014 NVSBE Post-Engagement Survey
213869	2014 NVSBE Events Satisfaction	Form and Instruction	New	Senior Leaders Roundtables
213869	2014 NVSBE Events Satisfaction	Form and Instruction	New	NRT Satisfaction
213869	2014 NVSBE Events Satisfaction	Form and Instruction	New	Learning Sessions
213869	2014 NVSBE Events Satisfaction	Form and Instruction	New	Exhibitor Satisfaction
213869	2014 NVSBE Events Satisfaction	Form and Instruction	New	CVE Booth Satisfaction
213869	2014 NVSBE Events Satisfaction	Form and Instruction	New	Business Requirement Sessions
213756	IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction Survey	Form and Instruction	New	Tobacco and Smoking Cessation Survey
213756	IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction Survey	Form and Instruction	New	Battlecreek Urgent Care Survey
213756	IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction Survey	Form and Instruction	New	VISN 1 Patient Satisfaction Survey
213756	IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction Survey	Form and Instruction	New	IOM VA Mental Health Services Evaluation
213756	IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction Survey	Form and Instruction	New	IOM VA Mental Health Services Evaluation
213756	IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction Survey	Form and Instruction	New	IOM VA Mental Health Services Evaluation
213752	Extended Hours Program Evaluation, Maternity Care Coordination, Advanced Education Veteran Survey, State Veterans Home Administrator Survey, VOV Conjoint Survey	Form and Instruction	New	Voice of the Veteran (VOV) Satisfaction Survey Office of Strategic Integration (OSI) Conjoint Analysis
213752	Extended Hours Program Evaluation, Maternity Care Coordination, Advanced Education Veteran Survey, State Veterans Home Administrator Survey, VOV Conjoint Survey	Form and Instruction	New	State Veterans Home Admin Survey
213752	Extended Hours Program Evaluation, Maternity Care Coordination, Advanced Education Veteran Survey, State Veterans Home Administrator Survey, VOV Conjoint Survey	Form and Instruction	New	Advanced Education Veteran Survey
213752	Extended Hours Program Evaluation, Maternity Care Coordination, Advanced Education Veteran Survey, State Veterans Home Administrator Survey, VOV Conjoint Survey	Form and Instruction	New	Maternity Care Coordination Survey
213752	Extended Hours Program Evaluation, Maternity Care Coordination, Advanced Education Veteran Survey, State Veterans Home Administrator Survey, VOV Conjoint Survey	Form and Instruction	New	Extended Hours Evaluation - Users
213752	Extended Hours Program Evaluation, Maternity Care Coordination, Advanced Education Veteran Survey, State Veterans Home Administrator Survey, VOV Conjoint Survey	Form and Instruction	New	Extended Hours Evaluation - Non-Users
213502	VA Office of Construction and Facilities Management (CFM) Supplier Satisfaction Survey Revision	Form and Instruction	New	CFM Supplier Satisfaction Survey
213368	OPA Patient Satisfaction, Audiology Survey, National Rollout Survey, Telehealth Survey	Form and Instruction	New	Telehealth Master Preceptor
213368	OPA Patient Satisfaction, Audiology Survey, National Rollout Survey, Telehealth Survey	Form and Instruction	New	Mental Health Survey
213368	OPA Patient Satisfaction, Audiology Survey, National Rollout Survey, Telehealth Survey	Form and Instruction	New	Audiology Hearing Aid Questionaire
213368	OPA Patient Satisfaction, Audiology Survey, National Rollout Survey, Telehealth Survey	Form and Instruction	New	Caribean Harvey Survey
213210	Health Research Multilevel Engagement, SORCC Patient Survey,	Form and Instruction	New	VHA OSI Primary Care Survey
213210	Health Research Multilevel Engagement, SORCC Patient Survey,	Form and Instruction	New	State Veterans Home Patient Satisfaction
213210	Health Research Multilevel Engagement, SORCC Patient Survey,	Form and Instruction	New	SOU-SORCC Patient Survey
213210	Health Research Multilevel Engagement, SORCC Patient Survey,	Form and Instruction	New	Womens Health Research Network
212980	OSDBU Post-Event Evaluation	Form	New	OSDBU Post-Event Evaluation
212897	Awards and ROI-2013 NVSBC	Form	New	Awards and ROI-2013 NVSBC
212897	Awards and ROI-2013 NVSBC	Form	New	Awards and ROI - 2013 NVSBC
212767	Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey	Form and Instruction	New	Prosthetics Customer Service Survey
212767	Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey	Form and Instruction	New	Patient Satisfaction Survey
212767	Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey	Form and Instruction	New	MH Veteran Survey
212767	Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey	Form and Instruction	New	HME Vendor Performance Survey
212045	2014 Post-9/11 GI Bill Communications Assessment	Other-Survey	New
210436	VISN 1 Call Center Customer Service Survey / OKC HB Primary Care Satisfaction Survey	Form	Modified	Oklahoma City VAMC Home Based Primary Care (HBPC) Program
210436	VISN 1 Call Center Customer Service Survey / OKC HB Primary Care Satisfaction Survey	Other-Script / Survey	Modified
210095	Survey of Patient Satisfaction at Surgical Service	Form	Modified	Spanish version: Survey of Patient Satisfaction at Surgical Services
210095	Survey of Patient Satisfaction at Surgical Service	Form	Modified	Survey of Patient Satisfaction at Surgical Service
209895	HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey	Form	Modified	Tele-Dermatology Imaging Patient Satisfaction Survey
209895	HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey	Form	Modified	Dental Insurance Program Survey
209895	HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey	Form	Modified	Non-VA-Purchased Care Veteran Survey
209895	HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey	Form	Modified	Home Based Primary Care Survey
209046	Rehabilitation Care Survey/HEC Vet Enrollment Survey/Project ARCH non-sub change	Form	Modified	Project ARCH Non-Participant Survey
209046	Rehabilitation Care Survey/HEC Vet Enrollment Survey/Project ARCH non-sub change	Form	Modified	HEC Enrollment Survey
209046	Rehabilitation Care Survey/HEC Vet Enrollment Survey/Project ARCH non-sub change	Form	Modified	Survey of Rehabilitation Care Survey
208635	National Patient Centered Community Care Survey Questions / Oklahoma City (OKC) VAMC Dental Patient Satisfaction Survey	Form	Modified	National Patient Centered Community Care Veterans Survey Question
208635	National Patient Centered Community Care Survey Questions / Oklahoma City (OKC) VAMC Dental Patient Satisfaction Survey	Form	Modified	Dental (Ambulatory) Patient Satisfaction Survey
208193	Outpatient Pharmacy Customer Satisfaction Survey	Form	Modified	Outpatient Pharmacy Customer Satisfaction Survey
207373	MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey	Form	Modified	Patient Survey: Waiting Room Television Video Patient Education
207373	MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey	Form	Modified	PROJECT ARCH (Access Received Closer to Home) Non-Participating Veterans Survey
207373	MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey	Form	Modified	MSCoE Patient Survey
206947	Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey	Form	Modified	Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey
206838	Boston VAMC Ophthamology Satisfaction Survey / VISN 20 Telephone Call Center Satisfaction Survey	Form	Modified	Telephone Customer Service Experience Satisfaction Survey
206838	Boston VAMC Ophthamology Satisfaction Survey / VISN 20 Telephone Call Center Satisfaction Survey	Form	Modified	Patient Satisfaction Survey_Boston VAMC_Dept. of Ophthamology
206725	Patient Satisfaction Surveys: Radiation Oncology/VISN 12 Telephone Care Service	Form	Modified	Telephone Care Services Patient Satisfaction Survey
206725	Patient Satisfaction Surveys: Radiation Oncology/VISN 12 Telephone Care Service	Form	Modified	Patient Satisfaction Survey- Radiation Oncology
206447	DeBakey Home Care Satisfaction Survey / CPEP Veterans Satisfaction Survey	Form	Modified	Compensation and Pension Examination Program (CPEP) Veterans Satisfaction Survey
206447	DeBakey Home Care Satisfaction Survey / CPEP Veterans Satisfaction Survey	Form and Instruction	Modified	Michael E. DeBakey Patient Satisfaction Survey
206171	Vet Apptmnt Apps Satisfaction Srvy/Hem-Oncology Telehealth Satisfaction Svy	Other-Mobile application	Modified
205929	VHA Customer Value Online Survey / Customer Value Focus Group	Other-Online Survey	Modified
205547	Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey	Form	Modified	Sodium Dichromate Exposure Exam Feedback Survey
205547	Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey	Form and Instruction	Modified	Building Better Caregivers Satisfaction Survey
205547	Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey	Form	Modified	Epilepsy Centers of Excellence (ECoE) Patient Satisfaction Survey
205547	Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey	Form	Modified	Fraud, Waste and Abuse Complaint Form
205547	Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey	Form	Modified	Food and Nutrition Satisfaction Survey
205012	PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey	Form	Modified	Phone Apps Focus Group Demographic Questionnaire
205012	PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey	Form	Modified	PTSD Coach App Survey
205012	PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey	Form	Modified	VA Courtesy Standards - The Golden Rule Approach Veteran Feedback Form
205012	PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey	Other-Telephone Script	Modified
205012	PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey	Form	Modified	Understanding PTSD for Family Caregivers: Feedback Survey
203264	VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction	Form	Modified	Office of Mental Health Veteran Satisfaction Survey
203264	VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction	Form	Modified	Dental Satisfaction Survey (Spanish version)
203264	VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction	Form	Modified	Dental Service Customer Satisfaction Survey
203264	VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction	Form	Modified	Patient Experience of Care Survey
203264	VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction	Other-Training Script	Modified
203264	VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction	Form	Modified	VCS Patriot Store and VCS Patriot Cafe Customer Satisfaction Survey
202594	Survey of Veterans Perceptions of an Enhanced VA Outpatient Prescription Label	Form	Modified	Rx Label Feedback
202280	Community Living Center (CLC) Satisfaction Survey; Cardiac Cath Lab Satisfaction Survey; Psychiatric Patient Survey	Form	Modified	Psychiatric Patient Satisfaction Survey
202280	Community Living Center (CLC) Satisfaction Survey; Cardiac Cath Lab Satisfaction Survey; Psychiatric Patient Survey	Form	Modified	Cardiac Cath Lab Customer Satisfaction Survey
202280	Community Living Center (CLC) Satisfaction Survey; Cardiac Cath Lab Satisfaction Survey; Psychiatric Patient Survey	Form	Modified	Community Living Center (CLC) Satisfaction Survey
201966	Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey	Other-Survey Cover Letter	Modified
201966	Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey	Form	Modified	Nuerology/Rehabilitation Inpatient Program Satisfaction Survey
201966	Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey	Form	Modified	Non-VA Care Coordination Veteran Satisfaction Survey
201966	Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey	Form	Modified	Survey of Veterans' Satisfaction with Income Verification
201966	Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey	Form	Modified	National Family Caregiver Participant Training Feedback Form
201966	Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey	Form	Modified	Spinal Cord Injury Patient Survey
200925	Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey	Other-Moderator Script	Modified
200925	Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey	Form	Modified	Spinal Cord Home Care Survey
200925	Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey	Form	Modified	Teleretinal Patient Satisfaction Survey
200925	Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey	Form	Modified	Purchased Care Patient Satisfaction Survey
200925	Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey	Form	Modified	Childcare Services Satisfaction Survey
200294	PACT Lab Caregiver and Patient Focus Groups; Point of Care (POC) Patient and Provider Focus Groups; Telehealth in the PADRECC: Veteran Focus Group; COMM Patient Survey; Office of Public Health Survey	Form	Modified	Office of Public Health Gulf War Newsletter Survey
200294	PACT Lab Caregiver and Patient Focus Groups; Point of Care (POC) Patient and Provider Focus Groups; Telehealth in the PADRECC: Veteran Focus Group; COMM Patient Survey; Office of Public Health Survey	Form	Modified	The Continuity of Medication Management Patient Survey
200294	PACT Lab Caregiver and Patient Focus Groups; Point of Care (POC) Patient and Provider Focus Groups; Telehealth in the PADRECC: Veteran Focus Group; COMM Patient Survey; Office of Public Health Survey	Other-guide/script	Modified
200161	VHA Generic Request: Notice Nurse Comment Card; Low Vision Clinic Patient Satisfaction Survey; Vendor Registration; Telephone Transformation Focus Group	Other-Script	Modified
200161	VHA Generic Request: Notice Nurse Comment Card; Low Vision Clinic Patient Satisfaction Survey; Vendor Registration; Telephone Transformation Focus Group	Form	Modified	Vendor Application for Fair
200161	VHA Generic Request: Notice Nurse Comment Card; Low Vision Clinic Patient Satisfaction Survey; Vendor Registration; Telephone Transformation Focus Group	Form	Modified	Notice Your Nurse
200161	VHA Generic Request: Notice Nurse Comment Card; Low Vision Clinic Patient Satisfaction Survey; Vendor Registration; Telephone Transformation Focus Group	Form	Modified	PVAMC Low Vision Patient Satisfaction Survey
199628	Project ARCH (Access received Closer to Home) Patient Satisfaction Survey	Form and Instruction	Modified	Project ARCH (Access Received Closer to Home) Patient Satisfaction Survey
199627	Telephone Survey on User Experience and Satisfaction with the Virtual Lifetime Electronic Record (VLER) Health Data Exchange	Other-Interviewer Script	Unchanged
199626	Patient Satisfaction Questionnaire: Network Consolidated Laboratory (NCL) Phlebotomy Service	Form	Modified	Patient Satisfaction Questionnaire: Laboratory P&LMS VA New England Healthcare System
199625	Clinical Video Telehealth (CVT) Patient Satisfaction Survey	Form	Modified	Clinical Video Telehealth (CVT) Patient Satisfaction Survey
199589	Veterans Transportation Service (VTS) Veterans Satisfaction Questionnaire	Form	Modified	Veterans Transportation Service (VTS) Questionnaire

ICR Details

OMB Control No: 2900-0770	ICR Reference No: 201403-2900-007
Status: Historical Active	Previous ICR Reference No: 201107-2900-001
Agency/Subagency: VA	Agency Tracking No: 2900-0770
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/21/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/27/2014
Terms of Clearance: OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2017	06/30/2014	08/31/2014
Responses	200,000	0	200,000
Time Burden (Hours)	100,000	0	100,000
Cost Burden (Dollars)	0	0	0

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Abstract: The generic clearance will be used to collect qualitative feedback on VA's services or products delivery. VA will seek customer and stakeholder perceptions, experiences and expectations on its services or products delivery. The data collected will be used to improve delivery of products or services in areas where needed.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standard
  

Citations for New Statutory Requirements: EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 59	03/27/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 123	06/26/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 91

table that charts list of burden

IC Title	Form No.	Form Name
2014 NVSBE Events Satisfaction	2900-0770, 2900-0770, 2900-0770, 2900-0770, 2900-0770, 2900-0770	Business Requirement Sessions ,   CVE Booth Satisfaction ,   Exhibitor Satisfaction ,   Learning Sessions ,   NRT Satisfaction ,   Senior Leaders Roundtables
2014 NVSBE Post-Engagement	2900-0770	2014 NVSBE Post-Engagement Survey
2014 Post-9/11 GI Bill Communications Assessment
Admission Process Customer Satisfaction Survey - Roseburg VAMC
Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey	VA Form 10-211002	Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey
Awards and ROI-2013 NVSBC	2900-0770, 2900-0770	Awards and ROI-2013 NVSBC ,   Awards and ROI - 2013 NVSBC
Board of Veterans Appeals Hearing Experience Surveys
Boston VAMC Ophthamology Satisfaction Survey / VISN 20 Telephone Call Center Satisfaction Survey	VA Form 10-211001NR, VA Form 10-10059	Patient Satisfaction Survey_Boston VAMC_Dept. of Ophthamology ,   Telephone Customer Service Experience Satisfaction Survey
CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score	10-10168, 10-10169, 10-10170, 10-10171, 10-10172	PIM Patient Letter ,   PIM Patient INterview Guide ,   PIM Stakeholder Interview ,   VPS Survey Questions ,   Watson's Caritas Patient Survey
CWT IT Consumers Satisfaction Survey_1
CWT IT Stakeholders Satisfaction Survey
CWT TW Consumers Satisfaction Survey
Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey	VA Form 10-0531, VA Form 10-0542, VA Form 10-0540, VA Form 10-0538	Childcare Services Satisfaction Survey ,   Purchased Care Patient Satisfaction Survey ,   Teleretinal Patient Satisfaction Survey ,   Spinal Cord Home Care Survey
Clinic Based Telehealth Satisfaction Survey	10-0481a	VA Telehealth Patient Survey
Clinical Video Telehealth (CVT) Patient Satisfaction Survey	VA Form 10-0481a	Clinical Video Telehealth (CVT) Patient Satisfaction Survey
Community Living Center (CLC) Satisfaction Survey; Cardiac Cath Lab Satisfaction Survey; Psychiatric Patient Survey	VA Form 10-0548, VA Form 10-0547, VA Form 10-0550	Community Living Center (CLC) Satisfaction Survey ,   Cardiac Cath Lab Customer Satisfaction Survey ,   Psychiatric Patient Satisfaction Survey
Community Residential Care
Congressional Response Team Customer Satisfaction Survey
Cooperative Studies Program	10-1500196(WS), 10-1500197(WS)	DMC Survey ,   CSPCC Study Chairperson and NSC Survey
Customer Satisfaction Survey for Claims Clinics Pilot Program
DeBakey Home Care Satisfaction Survey / CPEP Veterans Satisfaction Survey	VA Form 10-0476, VA Form 10-0480	Michael E. DeBakey Patient Satisfaction Survey ,   Compensation and Pension Examination Program (CPEP) Veterans Satisfaction Survey
Debt Management Center - Customer Service Experience
Extended Hours Program Evaluation, Maternity Care Coordination, Advanced Education Veteran Survey, State Veterans Home Administrator Survey, VOV Conjoint Survey	10-10132, 10-10131, 10-10128, 10-10136, 10-10129, 10-10144	Extended Hours Evaluation - Non-Users ,   Extended Hours Evaluation - Users ,   Maternity Care Coordination Survey ,   Advanced Education Veteran Survey ,   State Veterans Home Admin Survey ,   Voice of the Veteran (VOV) Satisfaction Survey Office of Strategic Integration (OSI) Conjoint Analysis
Feedback USA Button
Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey	VA Form 10-0498, VA Form 10-0500, VA Form 10-0558, VA Form 10-0499, VA Form 10-0559	Food and Nutrition Satisfaction Survey ,   Fraud, Waste and Abuse Complaint Form ,   Epilepsy Centers of Excellence (ECoE) Patient Satisfaction Survey ,   Building Better Caregivers Satisfaction Survey ,   Sodium Dichromate Exposure Exam Feedback Survey
HRC Satisfaction Survey
Health Advocate Survey
Health Advocate Survey
Health Research Multilevel Engagement, SORCC Patient Survey,	10-10147, 10-10145, 2900-0770, 10-10142	Womens Health Research Network ,   SOU-SORCC Patient Survey ,   State Veterans Home Patient Satisfaction ,   VHA OSI Primary Care Survey
HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey	VA Form 10-211016, VA Form 10-211014, VA Form 10-211013, VA Form 10-211011	Home Based Primary Care Survey ,   Non-VA-Purchased Care Veteran Survey ,   Dental Insurance Program Survey ,   Tele-Dermatology Imaging Patient Satisfaction Survey
IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction Survey	10-10128, 10-10130, 10-10133, 10-10136, 10-10131, 10-10135	IOM VA Mental Health Services Evaluation ,   IOM VA Mental Health Services Evaluation ,   IOM VA Mental Health Services Evaluation ,   VISN 1 Patient Satisfaction Survey ,   Battlecreek Urgent Care Survey ,   Tobacco and Smoking Cessation Survey
MFH Caregiver Survey
MFH Veteran Survey
MHICM Consumer Satisfaction Survey
MHV Summative Test
MHV Website Redesign, National Family Caregiver Survey, MEC Notification Survey	10-10155, 10-10119, 10-10114	MEC Notification Survey ,   Caregiver Feedback Form ,   National Family Caregiver Participant Training Feedback Form
MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey	VA Form 10-211004, VA Form 10-211003, VA Form 10-211005	MSCoE Patient Survey ,   PROJECT ARCH (Access Received Closer to Home) Non-Participating Veterans Survey ,   Patient Survey: Waiting Room Television Video Patient Education
Mental Health - SORCC
Mental Health - SORCC Satisfaction Survey
Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey	10-10122, 10-10123, 10-10126, 10-10125	HME Vendor Performance Survey ,   MH Veteran Survey ,   Patient Satisfaction Survey ,   Prosthetics Customer Service Survey
NAC Customer Response Survey
National Patient Centered Community Care Survey Questions / Oklahoma City (OKC) VAMC Dental Patient Satisfaction Survey	10-211009, 10-211008	National Patient Centered Community Care Veterans Survey Question ,   Dental (Ambulatory) Patient Satisfaction Survey
Non-VA Behavioral Health Care
OPA Patient Satisfaction, Audiology Survey, National Rollout Survey, Telehealth Survey	10-0526, 10-10128, 10-10129, 10-10127	Caribean Harvey Survey ,   Audiology Hearing Aid Questionaire ,   Mental Health Survey ,   Telehealth Master Preceptor
OSDBU Post-Event Evaluation	2900-0770	OSDBU Post-Event Evaluation
Outpatient Pharmacy Customer Satisfaction Survey	VA Fform 10-211006NR	Outpatient Pharmacy Customer Satisfaction Survey
PACT Lab Caregiver and Patient Focus Groups; Point of Care (POC) Patient and Provider Focus Groups; Telehealth in the PADRECC: Veteran Focus Group; COMM Patient Survey; Office of Public Health Survey	VA Form 10-0526, Article and Volume Number of Newsletter	The Continuity of Medication Management Patient Survey ,   Office of Public Health Gulf War Newsletter Survey
PTSD Consultation Program
PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey	VA Form 10-0496, VA Form 10-0495, VA Form 10-0497, VA Form 10-0496a	Understanding PTSD for Family Caregivers: Feedback Survey ,   VA Courtesy Standards - The Golden Rule Approach Veteran Feedback Form ,   PTSD Coach App Survey ,   Phone Apps Focus Group Demographic Questionnaire
Patient Satisfaction Questionnaire: Network Consolidated Laboratory (NCL) Phlebotomy Service	VA Form 10-0516	Patient Satisfaction Questionnaire: Laboratory P&LMS VA New England Healthcare System
Patient Satisfaction Surveys: Radiation Oncology/VISN 12 Telephone Care Service	VA Form 10-10063, VA Form 10-10058	Patient Satisfaction Survey- Radiation Oncology ,   Telephone Care Services Patient Satisfaction Survey
Primary Care Satisfaction and Effectiveness Survey
Project ARCH (Access received Closer to Home) Patient Satisfaction Survey	VA Form 10-0522	Project ARCH (Access Received Closer to Home) Patient Satisfaction Survey
Rehabilitation Care Survey/HEC Vet Enrollment Survey/Project ARCH non-sub change	VA Form 10-211004, VA Form 10-211010, VA Form 10-211013	Survey of Rehabilitation Care Survey ,   HEC Enrollment Survey ,   Project ARCH Non-Participant Survey
Rehabilitation and Audiology Customer Service Survey
Shared Decision Making
Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey	VA Form 10-0515, VA Form 10-0520, VA Form 10-0541, VA Form 10-0545, VA Form 10-0546	Spinal Cord Injury Patient Survey ,   National Family Caregiver Participant Training Feedback Form ,   Survey of Veterans' Satisfaction with Income Verification ,   Non-VA Care Coordination Veteran Satisfaction Survey ,   Nuerology/Rehabilitation Inpatient Program Satisfaction Survey
Supplier Perception Survey
Survey of Patient Satisfaction at Surgical Service	VA Form 10-211015, VA Form 10-211015SP	Survey of Patient Satisfaction at Surgical Service ,   Spanish version: Survey of Patient Satisfaction at Surgical Services
Survey of Veterans Perceptions of an Enhanced VA Outpatient Prescription Label	VA Form 10-0549	Rx Label Feedback
Survey regarding effectiveness of the GI Bill Feedback System
Telebenefits Satisfaction Survey
Telephone Survey on User Experience and Satisfaction with the Virtual Lifetime Electronic Record (VLER) Health Data Exchange
VA Conjoint Survey - External Communication	10-1500188(WS)	VA External Communication Conjoint Questionnaire
VA Office of Construction and Facilities Management (CFM) Supplier Satisfaction Survey Revision	VA Form 10163	CFM Supplier Satisfaction Survey
VA Pittsburgh Health Care System Emergency Department Survey
VA Pittsburgh Reseach Survey
VACT Primary Care Patient Satisfaction Questionnaire
VAInfoApp	10-1500199(WS)	MySurvey
VAR Mobile App Rev_8-2016
VCP_VACC Provider Survey	10-1500210(WS), 10-1500209(WS)	VACC Provider Survey ,   VCP Provider Survey
VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction	VA Form 10-0551, VA Form 10-0553S, VA form 10-0552, VA form 10-0553, VA Form 10-0554	VCS Patriot Store and VCS Patriot Cafe Customer Satisfaction Survey ,   Patient Experience of Care Survey ,   Dental Service Customer Satisfaction Survey ,   Dental Satisfaction Survey (Spanish version) ,   Office of Mental Health Veteran Satisfaction Survey
VE Access Survey Questions
VE Feedback Tool: eComment Card
VHA Customer Value Online Survey / Customer Value Focus Group
VHA Generic Request: Notice Nurse Comment Card; Low Vision Clinic Patient Satisfaction Survey; Vendor Registration; Telephone Transformation Focus Group	VA form 10-0519, VA Form 10-0528, VA Form 10-0527	PVAMC Low Vision Patient Satisfaction Survey ,   Notice Your Nurse ,   Vendor Application for Fair
VHA Women Veterans Call Center
VISN 1 Call Center Customer Service Survey / OKC HB Primary Care Satisfaction Survey	VA Form 10-211014a	Oklahoma City VAMC Home Based Primary Care (HBPC) Program
VISN 20 Cancer Care Survey, VA Research Currents	VA Form 10-10167, VA Form 10-10164	VISN 20 Cancer Care Survey ,   Customer Satisfaction Survey on VA Research Communication, VA Research Currents
Verification Cost of Compliance
Vet Apptmnt Apps Satisfaction Srvy/Hem-Oncology Telehealth Satisfaction Svy
Veteran Experience and Satisfaction with the Department of Veteran Affairs Compensation and Pension Claims Examination
Veteran Experience and Satisfaction with the Department of Veterans Affairs Compensation and Pension Claims Examination Survey
Veterans Affairs Acquisition 360 Survey
Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care	10-0552, 10-0450, 10-0455, 10-0457	Veterans Choice Program Survey ,   Nationwide Dialysis Program Survey ,   VLER Program Survey ,   Patient Experience of Care Survey
Veterans Experience Appointment Schedule Survey
Veterans Experience Appointment Schedule Survey (Rev)
Veterans Experience Initiative	10-0516, 10-0476	NCL Patient Satisfaction Questionnaire ,   Michael E. DeBakey Home Care Program
Veterans Millennium Act Emergency Care Benefit Satisfaction Survey
Veterans Transportation Service (VTS) Veterans Satisfaction Questionnaire	VA Form 10-0517	Veterans Transportation Service (VTS) Questionnaire
Voice of the Customer Questionnaire for Pharmacy Choice

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	200,000	200,000	0	0	0	0
Annual Time Burden (Hours)	100,000	100,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: New Collection.

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Annual Cost to Federal Government: $300,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/27/2014

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