Information Collection

IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction Survey

IC 213756 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⚠️ Notice: This information collection may be referencing outdated material.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 10-10128 IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction Survey	Form and Instruction
10-10128 IOM VA Mental Health Services Evaluation 09-IOM VA MH Services Eval Non-VA Service Users Discussion Protocol 10-01-14-1.docx	Form and Instruction
10-10130 IOM VA Mental Health Services Evaluation 10-IOM VA MH Services Eval Fam Friends Non-VA Service Users Discussion Protocol 10-01-14.docx	Form and Instruction
10-10131 IOM VA Mental Health Services Evaluation 12-IOM VA MH Services Eval Non-VA Clinical Staff Discussion Protocol 10-03-14.docx	Form and Instruction
10-10133 VISN 1 Patient Satisfaction Survey NCL Patient Satisfaction Questionnaire 6- 2011 final approved by OMB-1.docx	Form and Instruction
10-10135 Battlecreek Urgent Care Survey Battlecreek Urgent Care Survey.docx	Form and Instruction
10-10136 Tobacco and Smoking Cessation Survey smoking cessation.docx	Form and Instruction
IOM Discussion Groups_VA Generic Fast-Track Clearance Request_2014-11-04.docx IOM Generic Clearance Request	IC Document
Generic_Clearance_Submission_Template_Endo-WHAV.docx Patient Satisfaction Questionaire Generic Clearance	IC Document
VA Generic Fast-Track Clearance Request Template_20131216.docx Smoking and Nicotine Use Generic Clearance	IC Document
VA Generic Fast-Track Clearance Request Urgent Care.docx Battle Creek Urgent Care Generic Clearance	IC Document

IC Title:

IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction 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	10-10128	IOM VA Mental Health Services Evaluation	09-IOM VA MH Services Eval Non-VA Service Users Discussion Protocol 10-01-14-1.docx	No	Fillable Printable
Form and Instruction	10-10130	IOM VA Mental Health Services Evaluation	10-IOM VA MH Services Eval Fam Friends Non-VA Service Users Discussion Protocol 10-01-14.docx	No	Fillable Printable
Form and Instruction	10-10131	IOM VA Mental Health Services Evaluation	12-IOM VA MH Services Eval Non-VA Clinical Staff Discussion Protocol 10-03-14.docx	No	Fillable Printable
Form and Instruction	10-10133	VISN 1 Patient Satisfaction Survey	NCL Patient Satisfaction Questionnaire 6- 2011 final approved by OMB-1.docx	No	Fillable Printable
Form and Instruction	10-10135	Battlecreek Urgent Care Survey	Battlecreek Urgent Care Survey.docx	No	Fillable Printable
Form and Instruction	10-10136	Tobacco and Smoking Cessation Survey	smoking cessation.docx	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,990

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	2,990	2,990
Annual IC Time Burden (Hours)	897	897
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
IOM Generic Clearance Request	IOM Discussion Groups_VA Generic Fast-Track Clearance Request_2014-11-04.docx	11/06/2014
Patient Satisfaction Questionaire Generic Clearance	Generic_Clearance_Submission_Template_Endo-WHAV.docx	11/06/2014
Smoking and Nicotine Use Generic Clearance	VA Generic Fast-Track Clearance Request Template_20131216.docx	11/06/2014
Battle Creek Urgent Care Generic Clearance	VA Generic Fast-Track Clearance Request Urgent Care.docx	11/06/2014

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