Information Collection

Project ARCH (Access received Closer to Home) Patient Satisfaction Survey

IC 199628 under ICR 201403-2900-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 10-0522 Project ARCH (Access received Closer to Home) Patient Satisfaction Survey	Form and Instruction
VA Form 10-0522 Project ARCH (Access Received Closer to Home) Patient Sa ARCH Patient Survey VA Form 10-0522.pdf	Form and Instruction
10-0504-fill consent form.pdf Consent Form	IC Document
ARCH_Patient Satisfaction Cover Letter.doc ARCH Patient Satisfaction Cover Letter	IC Document
ELIGIBILITY REQUIREMENTS FOR PROJECT ARCH.docx Eligibility Requirements for Project ARCH	IC Document
Generic_Submission_Project_ARCH 11-17 correction.docx Generic Submission Request_Project ARCH 11_17	IC Document

IC Title:

Project ARCH (Access received Closer to Home) Patient Satisfaction Survey

Agency IC Tracking Number:

2900-0770

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320.8(d)

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 10-0522	Project ARCH (Access Received Closer to Home) Patient Satisfaction Survey	ARCH Patient Survey VA Form 10-0522.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	7,200	7,200
Annual IC Time Burden (Hours)	1,440	1,440
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Form	10-0504-fill consent form.pdf	11/07/2011
ARCH Patient Satisfaction Cover Letter	ARCH_Patient Satisfaction Cover Letter.doc	11/14/2011
Eligibility Requirements for Project ARCH	ELIGIBILITY REQUIREMENTS FOR PROJECT ARCH.docx	11/14/2011
Generic Submission Request_Project ARCH 11_17	Generic_Submission_Project_ARCH 11-17 correction.docx	11/17/2011

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