Information Collection

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

IC 217630 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⚠️ Notice: This information collection may be referencing outdated material.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 10-10168 PIM Patient Letter CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score	Form and Instruction
Form 10-10169 PIM Patient INterview Guide CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score	Form and Instruction
Form 10-10170 PIM Stakeholder Interview CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score	Form and Instruction
Form 10-10171 VPS Survey Questions CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score	Form and Instruction
Form 10-10172 Watson's Caritas Patient Survey 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

View Information Collection (IC)

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:

table that charts list of 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

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: 5,350

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	5,350	5,350
Annual IC Time Burden (Hours)	467	467
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.