Information Collection

Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care

IC 215611 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⚠️ Notice: This information collection may be referencing outdated material.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 10-0450 Veterans Choice Program Survey Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care	Form and Instruction
Form 10-0455 Nationwide Dialysis Program Survey Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care	Form and Instruction
Form 10-0457 VLER Program Survey Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care	Form and Instruction
Form 10-0552 Patient Experience of Care Survey Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care	Form and Instruction
10-0450 Veterans Choice Program Survey VCP Survey 030215_For OMB Submission_v6 updated (3)CLEAN.docx	Form and Instruction
10-0455 Nationwide Dialysis Program Survey Nationwide Dialysis Contracts Program Veterans Survey.docx	Form and Instruction
10-0457 VLER Program Survey VLER Exchange_Undecided Vet Interview Guide_011315.docx	Form and Instruction
10-0552 Patient Experience of Care Survey Patient Experiences Survey_10-0552.doc	Form and Instruction
OMB fast track for VA VCP 3.2.15_updated CLEAN.doc Veterans Choice Program Fast Track Request	IC Document
Nationwide Dialysis Contracts Veterans Survey Information Collection Package 20141212.docx Nationwide Dialysis Program Fast Track Request	IC Document
VLER _Generic_Clearance_Request Form 01_20_15.docx VLER Fast Track Request	IC Document
Generic_Submission_Request EM Patient Survey.docx Generic Clearance Request - Patient Experience Survey	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care

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	10-0450	Veterans Choice Program Survey	VCP Survey 030215_For OMB Submission_v6 updated (3)CLEAN.docx	No	Fillable Printable
Form and Instruction	10-0455	Nationwide Dialysis Program Survey	Nationwide Dialysis Contracts Program Veterans Survey.docx	No	Fillable Printable
Form and Instruction	10-0457	VLER Program Survey	VLER Exchange_Undecided Vet Interview Guide_011315.docx	No	Fillable Printable
Form and Instruction	10-0552	Patient Experience of Care Survey	Patient Experiences Survey_10-0552.doc	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,045

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	10,045	10,045
Annual IC Time Burden (Hours)	1,339	1,339
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Veterans Choice Program Fast Track Request	OMB fast track for VA VCP 3.2.15_updated CLEAN.doc	03/06/2015
Nationwide Dialysis Program Fast Track Request	Nationwide Dialysis Contracts Veterans Survey Information Collection Package 20141212.docx	03/06/2015
VLER Fast Track Request	VLER _Generic_Clearance_Request Form 01_20_15.docx	03/06/2015
Generic Clearance Request - Patient Experience Survey	Generic_Submission_Request EM Patient Survey.docx	03/26/2015

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