CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0770 can be found here:

Documents and Forms

Document Name Document Type
Form 10-10168 CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score Form and Instruction
10-10168 PIM Patient Letter PIM_Patient Letter.docx Form and Instruction
10-10169 PIM Patient INterview Guide PIM patient interview guide_revised 6.19.15.docx Form and Instruction
10-10170 PIM Stakeholder Interview PIM Key Stakeholder Interview QA_patients.docx Form and Instruction
10-10171 VPS Survey Questions VPS survey questions.docx Form and Instruction
10-10172 Watson's Caritas Patient Survey Watson's Caritas Patient Survey OMB 120415.docx Form and Instruction
VA Generic Fast-Track Clearance Request VPS 062315.docx Veteran Patient Satisfaction Generic Clearance IC Document
Justification for Caritas Survey.docx Justification IC Document
VA Generic Fast-Track Clearance Request Template Caritas Version.docx Watson's Caritas Generic Clearance Request IC Document
VA Generic Fast-Track Clearance Request - PIM Evaluation with sig_corrected.docx PIM Generic Clearance Request IC Document
Permission for Caritas Survey_120715.docx Permission for Survey IC Document

Information Collection (IC) Details

IC Title:	CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	10-10168	PIM Patient Letter	PIM_Patient Letter.docx	No	Paper Only
Form and Instruction	10-10169	PIM Patient INterview Guide	PIM patient interview guide_revised 6.19.15.docx	No	Paper Only
Form and Instruction	10-10170	PIM Stakeholder Interview	PIM Key Stakeholder Interview QA_patients.docx	No	Paper Only
Form and Instruction	10-10171	VPS Survey Questions	VPS survey questions.docx	No	Fillable Printable
Form and Instruction	10-10172	Watson's Caritas Patient Survey	Watson's Caritas Patient Survey OMB 120415.docx	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,350	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,350	5,350
Annual IC Time Burden (Hours)	467	467
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Veteran Patient Satisfaction Generic Clearance	VA Generic Fast-Track Clearance Request VPS 062315.docx	07/23/2015
Justification	Justification for Caritas Survey.docx	10/09/2015
Watson's Caritas Generic Clearance Request	VA Generic Fast-Track Clearance Request Template Caritas Version.docx	10/13/2015
PIM Generic Clearance Request	VA Generic Fast-Track Clearance Request - PIM Evaluation with sig_corrected.docx	10/15/2015
Permission for Survey	Permission for Caritas Survey_120715.docx	12/07/2015

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