Information Collection

Health Research Multilevel Engagement, SORCC Patient Survey,

IC 213210 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⚠️ Notice: This information collection may be referencing outdated material.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 10-10142 Health Research Multilevel Engagement, SORCC Patient Survey,	Form and Instruction
10-10142 Womens Health Research Network Womens Health Research Network.docx	Form and Instruction
10-10145 SOU-SORCC Patient Survey SOU-SORCC-Patient-Survey-2.docx	Form and Instruction
2900-0770 State Veterans Home Patient Satisfaction SVH Questions.docx	Form and Instruction
10-10147 VHA OSI Primary Care Survey VHA_OSI Conjoint_Primary Care_Survey_11-21-14 Final.doc	Form and Instruction
Generic_Clearance_Submission_HAMILTON 091514 patients only_AH.docx Womens Health Research	IC Document
VA SORCC Request 9 5 14.docx SORCC Request	IC Document
Generic_Clearance SVH Satisfaction.docx SVH Satisfaction	IC Document
VA Generic Fast-Track Clearance Request_VHA OSI Primary Care Conjoint Analysis_11 21 14.docx OSI Primary Care Fast Track Request	IC Document

IC Title:

Health Research Multilevel Engagement, SORCC Patient 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	10-10142	Womens Health Research Network	Womens Health Research Network.docx	No	Fillable Printable
Form and Instruction	10-10145	SOU-SORCC Patient Survey	SOU-SORCC-Patient-Survey-2.docx	No	Fillable Printable
Form and Instruction	2900-0770	State Veterans Home Patient Satisfaction	SVH Questions.docx	No	Fillable Printable
Form and Instruction	10-10147	VHA OSI Primary Care Survey	VHA_OSI Conjoint_Primary Care_Survey_11-21-14 Final.doc	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,477

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	4,477	4,477
Annual IC Time Burden (Hours)	1,067	1,067
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Womens Health Research	Generic_Clearance_Submission_HAMILTON 091514 patients only_AH.docx	09/23/2014
SORCC Request	VA SORCC Request 9 5 14.docx	09/23/2014
SVH Satisfaction	Generic_Clearance SVH Satisfaction.docx	09/23/2014
OSI Primary Care Fast Track Request	VA Generic Fast-Track Clearance Request_VHA OSI Primary Care Conjoint Analysis_11 21 14.docx	12/19/2014

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