Information Collection

Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey

IC 212767 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⚠️ Notice: This information collection may be referencing outdated material.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 10-10122 HME Vendor Performance Survey Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey	Form and Instruction
Form 10-10123 MH Veteran Survey Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey	Form and Instruction
Form 10-10126 Patient Satisfaction Survey Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey	Form and Instruction
Form 10-10125 Prosthetics Customer Service Survey Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey	Form and Instruction
10-10122 HME Vendor Performance Survey HME Vendor Performance Survey 2014 (CR 8 22 14).docx	Form and Instruction
10-10123 MH Veteran Survey MH Veteran Survey (CR 8 21 14).docx	Form and Instruction
10-10126 Patient Satisfaction Survey Prothetics Customer survey FY14 (CR 8 22 14 v2).docx	Form and Instruction
10-10125 Prosthetics Customer Service Survey Prothetics Customer survey FY14 (CR 8 21 14 v1)-3.docx	Form and Instruction
Prosthesis Fast-Track Clearance Request.pdf HME Fast Track	IC Document
Prosthesis Fast-Track Clearance Request.pdf Patient Satisfaction Survey Fast Track	IC Document
ProthesticsCustomer Fast-Track Clearance Request.pdf Internal Satisfaction Fast Track	IC Document
VeteransSurvey2014application.docx MH Survey Fast Track	IC Document

IC Title:

Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey

Agency IC Tracking Number:

2900-0770

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	10-10122	HME Vendor Performance Survey	HME Vendor Performance Survey 2014 (CR 8 22 14).docx	No	Fillable Printable
Form and Instruction	10-10123	MH Veteran Survey	MH Veteran Survey (CR 8 21 14).docx	No	Fillable Printable
Form and Instruction	10-10126	Patient Satisfaction Survey	Prothetics Customer survey FY14 (CR 8 22 14 v2).docx	No	Fillable Printable
Form and Instruction	10-10125	Prosthetics Customer Service Survey	Prothetics Customer survey FY14 (CR 8 21 14 v1)-3.docx	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,160

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,160	3,160
Annual IC Time Burden (Hours)	1,317	1,317
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HME Fast Track	Prosthesis Fast-Track Clearance Request.pdf	08/21/2014
Patient Satisfaction Survey Fast Track	Prosthesis Fast-Track Clearance Request.pdf	08/21/2014
Internal Satisfaction Fast Track	ProthesticsCustomer Fast-Track Clearance Request.pdf	08/21/2014
MH Survey Fast Track	VeteransSurvey2014application.docx	08/21/2014

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