Information Collection

Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey

IC 205547 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⚠️ Notice: This information collection may be referencing outdated material.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 10-0498 Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey	Form
VA Form 10-0498 Food and Nutrition Satisfaction Survey Food and Nutrition Survey_10-0498.pdf	Form
VA Form 10-0500 Fraud, Waste and Abuse Complaint Form Fraud Complaint Form_10-0500.pdf To Be Determined	Form
VA Form 10-0558 Epilepsy Centers of Excellence (ECoE) Patient Satisfacti ECoE Patient Satisfaction Survey_10-0558.pdf To Be Determined	Form
VA Form 10-0499 Building Better Caregivers Satisfaction Survey BuildBetterCaregivers - 10-0499 Survey.pdf.pdf Follow up Telephone Script	Form and Instruction
VA Form 10-0559 Sodium Dichromate Exposure Exam Feedback Survey Survey Feedback_Sodium Dichromate Exam 10-0559.pdf	Form
Food and Nutrition Survey_Generic_Submission_2012.docx Food and Nutrition Satisfaction Survey	IC Document
Fraud Complaint Form Generic Request_v2_.docx Fraud, Waste, and Abuse Complaint Form	IC Document
Generic Submission - ECoE Patient Satisfaction Survey (2).docx Epilepsy Centers of Excellence (ECoE) Satisfaction Survey	IC Document
BuildBetterCaregiver Generic_Submission (v4).docx Building Better Caregivers Satisfaction Survey	IC Document
Sodium Dichromate Exposure Survey_Generic_Request.docx Sodium Dichromate Exposure Exam Feedback	IC Document

IC Title:

Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey

Agency IC Tracking Number:

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	VA Form 10-0498	Food and Nutrition Satisfaction Survey	Food and Nutrition Survey_10-0498.pdf		No		Paper Only
Form	VA Form 10-0500	Fraud, Waste and Abuse Complaint Form	Fraud Complaint Form_10-0500.pdf	To Be Determined	Yes	Yes	Fillable Fileable
Form	VA Form 10-0558	Epilepsy Centers of Excellence (ECoE) Patient Satisfaction Survey	ECoE Patient Satisfaction Survey_10-0558.pdf	To Be Determined	Yes	Yes	Fillable Fileable
Form and Instruction	VA Form 10-0499	Building Better Caregivers Satisfaction Survey	BuildBetterCaregivers - 10-0499 Survey.pdf.pdf	Follow up Telephone Script	No		Fillable Printable
Form	VA Form 10-0559	Sodium Dichromate Exposure Exam Feedback Survey	Survey Feedback_Sodium Dichromate Exam 10-0559.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 129,980

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	129,980	129,980
Annual IC Time Burden (Hours)	4,941	4,941
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Food and Nutrition Satisfaction Survey	Food and Nutrition Survey_Generic_Submission_2012.docx	01/27/2013
Fraud, Waste, and Abuse Complaint Form	Fraud Complaint Form Generic Request_v2_.docx	01/27/2013
Epilepsy Centers of Excellence (ECoE) Satisfaction Survey	Generic Submission - ECoE Patient Satisfaction Survey (2).docx	01/27/2013
Building Better Caregivers Satisfaction Survey	BuildBetterCaregiver Generic_Submission (v4).docx	01/27/2013
Sodium Dichromate Exposure Exam Feedback	Sodium Dichromate Exposure Survey_Generic_Request.docx	01/27/2013

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