Information Collection

HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey

IC 209895 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form VA Form 10-211014 HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey Form
VA Form 10-211014 Home Based Primary Care Survey LawtonCBOC HB Primary Care Survey_10-211014.pdf Form
VA Form 10-211013 Non-VA-Purchased Care Veteran Survey VA Form 10-211013_Non-VA PC Survey_10-2013.pdf URL to be determined Form
VA Form 10-211011 Dental Insurance Program Survey VA Form 10-211011 Dental Insurance Survey 10-13.pdf URL to be determined Form
VA Form 10-211016 Tele-Dermatology Imaging Patient Satisfaction Survey Tele-Dermatology Satisfaction Survey 10-211016.pdf TeleForm software will be used: URL TBD Form
Generic Submission_Home Based Primary Care.docx Home Based Primary Care Patient Satisfaction IC Document
HBPC Survey Letter OKC.doc HBPC Survey Letter OKC/Lawton IC Document
VA Generic_Request_PurchasedCare Veteran Survey (v5)11-13.docx NonVA Purchased Care Veteran Survey IC Document
Generic_Submission_Dental Insurance Survey.docx Dental Insurance Survey IC Document
Generic Request TeleDermatology Survey 01-28-14 (v2).docx Teledermatology Imaging Patient Satisfaction Survey IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey	Agency IC Tracking Number:

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 10-211014	Home Based Primary Care Survey	LawtonCBOC HB Primary Care Survey_10-211014.pdf		No		Paper Only
Form	VA Form 10-211013	Non-VA-Purchased Care Veteran Survey	VA Form 10-211013_Non-VA PC Survey_10-2013.pdf	URL to be determined	Yes	Yes	Fillable Fileable
Form	VA Form 10-211011	Dental Insurance Program Survey	VA Form 10-211011 Dental Insurance Survey 10-13.pdf	URL to be determined	Yes	Yes	Fillable Fileable
Form	VA Form 10-211016	Tele-Dermatology Imaging Patient Satisfaction Survey	Tele-Dermatology Satisfaction Survey 10-211016.pdf	TeleForm software will be used: URL TBD	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14,320	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	14,320	14,320
Annual IC Time Burden (Hours)	1,388	1,388
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Home Based Primary Care Patient Satisfaction	Generic Submission_Home Based Primary Care.docx	12/30/2013
HBPC Survey Letter OKC/Lawton	HBPC Survey Letter OKC.doc	12/30/2013
NonVA Purchased Care Veteran Survey	VA Generic_Request_PurchasedCare Veteran Survey (v5)11-13.docx	12/30/2013
Dental Insurance Survey	Generic_Submission_Dental Insurance Survey.docx	12/30/2013
Teledermatology Imaging Patient Satisfaction Survey	Generic Request TeleDermatology Survey 01-28-14 (v2).docx	01/29/2014

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