Information Collection

Bereaved Family Member Satisfaction Survey

IC 178992 under ICR 201411-2900-004 · OMB 2900-0701.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-21081(N Bereaved Family Member Satisfaction Survey	Form
VA Form 10-21081(N Bereaved Family Member Satisfaction Survey_Administered Bereaved Family Member Satisfaction Survey_Administered by Facility Staff.doc	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 10-21081(NR)	Bereaved Family Member Satisfaction Survey_Administered by Facility Staff	Bereaved Family Member Satisfaction Survey_Administered by Facility Staff.doc		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13,500

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	Previously Approved
Annual Number of Responses for this IC	13,500	2,500	11,000
Annual IC Time Burden (Hours)	2,250	417	1,833
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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