Information Collection

Survey of Patient Satisfaction at Surgical Service

IC 210095 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⚠️ Notice: This information collection may be referencing outdated material.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 10-211015 Survey of Patient Satisfaction at Surgical Service Survey of Patient Satisfaction at Surgical Service	Form
Form VA Form 10-211015S Spanish version: Survey of Patient Satisfaction at Surgical Services Survey of Patient Satisfaction at Surgical Service	Form
VA Form 10-211015 Survey of Patient Satisfaction at Surgical Service Surgical Patient Satisfaction Survey_10-211015.pdf	Form
VA Form 10-211015S Spanish version: Survey of Patient Satisfaction at Surgi Spanish_version Surgical Survey_10-211015SP.pdf	Form
Generic Request_Surgical Patient Satisfaction Survey 1-14.docx Generic Request Surgical Patient Satisfaction Survey 1-2014	IC Document
Daily Schedule of Surgery Sample.pdf Daily Schedule of Surgery Sample	IC Document

IC Title:

Survey of Patient Satisfaction at Surgical Service

Agency IC Tracking Number:

IC Status: Modified

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	VA Form 10-211015				No		Paper Only
Form	VA Form 10-211015SP				No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,825

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	1,825	1,825
Annual IC Time Burden (Hours)	608	608
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Request Surgical Patient Satisfaction Survey 1-2014		01/22/2014
Daily Schedule of Surgery Sample		01/22/2014

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

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