Information Collection

OPA Patient Satisfaction, Audiology Survey, National Rollout Survey, Telehealth Survey

IC 213368 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⚠️ Notice: This information collection may be referencing outdated material.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 10-0526 OPA Patient Satisfaction, Audiology Survey, National Rollout Survey, Telehealth Survey	Form and Instruction
10-0526 Caribean Harvey Survey Patient Satisfaction Survey.docx	Form and Instruction
10-10128 Audiology Hearing Aid Questionaire Audiology - hearing aid questionaire.docx	Form and Instruction
10-10129 Mental Health Survey MH Veteran Survey (CR 8 21 14).docx	Form and Instruction
10-10127 Telehealth Master Preceptor Telehealth Master Preceptor (CR 10314).docx	Form and Instruction
caribbean Harvey_Generic_Clearance_Submission_Template_(2)1.docx Caribbean fast track	IC Document
VA Generic Fast-Track Clearance Request Template_20131216 for IOI-HA.docx Audiology Questionaire	IC Document
VeteransSurvey2014application.docx MH Survey Fast Track	IC Document
VA Generic Fast-Track Clearance Request Template_20131216- gallarno.docx Telehealth Survey Fast Track	IC Document

IC Title:

OPA Patient Satisfaction, Audiology Survey, National Rollout Survey, Telehealth 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	10-0526	Caribean Harvey Survey	Patient Satisfaction Survey.docx	No	Fillable Printable
Form and Instruction	10-10128	Audiology Hearing Aid Questionaire	Audiology - hearing aid questionaire.docx	No	Fillable Printable
Form and Instruction	10-10129	Mental Health Survey	MH Veteran Survey (CR 8 21 14).docx	No	Fillable Printable
Form and Instruction	10-10127	Telehealth Master Preceptor	Telehealth Master Preceptor (CR 10314).docx	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,366

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	10,366	10,366
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Caribbean fast track	caribbean Harvey_Generic_Clearance_Submission_Template_(2)1.docx	10/02/2014
Audiology Questionaire	VA Generic Fast-Track Clearance Request Template_20131216 for IOI-HA.docx	10/02/2014
MH Survey Fast Track	VeteransSurvey2014application.docx	10/02/2014
Telehealth Survey Fast Track	VA Generic Fast-Track Clearance Request Template_20131216- gallarno.docx	10/02/2014

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