NOA Fast Track-Dec 10, 2014

NOTICE OF OFFICE OF MANAGEMENT AND BUDGET ACTION
Date

12/10/2014

Department of Veterans Affairs

FOR CERTIFYING OFFICIAL:

Roger Baker

FOR CLEARANCE OFFICER:

Crystal Rennie

In accordance with the Paperwork Reduction Act, OMB has taken action on your request received
12/02/2014
ACTION REQUESTED:

Generic IC

TYPE OF REVIEW REQUESTED:
ICR REFERENCE NUMBER:

201403-2900-007

AGENCY ICR TRACKING NUMBER:

2900-0770

TITLE:

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA,
VBA, VHA)
LIST OF INFORMATION COLLECTIONS: See next page
OMB ACTION: Approved without change
OMB CONTROL NUMBER:

2900-0770

The agency is required to display the OMB Control Number and inform respondents of its legal significance in
accordance with 5 CFR 1320.5(b).
EXPIRATION DATE:

DISCONTINUE DATE:

BURDEN:

RESPONSES

HOURS

COSTS

Previous

200,000

100,000

0

New

200,000

100,000

0

Change due to New Statute

0

0

0

Change due to Agency Discretion

0

0

0

Change due to Agency Adjustment

0

0

0

Change due to PRA Violation

0

0

0

Difference

TERMS OF CLEARANCE:

Terms of the Generic ICR remain in effect.

OMB Authorizing Official:

Dominic J. Mancini
Acting Deputy Administrator,
Office Of Information And Regulatory Affairs

IC Title

Form No.

List of ICs
Form Name

CFR Citation

Veterans Transportation VA Form 10-0517
Veterans Transportation 5 CFR 1320.8(d)
Service (VTS) Veterans
Service (VTS)
Satisfaction
Questionnaire
Questionnaire
Clinical Video
VA Form 10-0481a
Clinical Video Telehealth 5 CFR 1320.8(d)
Telehealth (CVT)
(CVT) Patient Satisfaction
Patient Satisfaction
Survey
Survey
Patient Satisfaction
VA Form 10-0516
Patient Satisfaction
5 CFR 1320.8(d)
Questionnaire: Network
Questionnaire: Laboratory
Consolidated
P&LMS VA New England
Laboratory (NCL)
Healthcare System
Phlebotomy Service
Telephone Survey on
5 CFR 1320.8(d)
User Experience and
Satisfaction with the
Virtual Lifetime
Electronic Record
(VLER) Health Data
Exchange
Project ARCH (Access VA Form 10-0522
Project ARCH (Access
5 CFR 1320.8(d)
received Closer to
Received Closer to Home)
Home) Patient
Patient Satisfaction
Satisfaction Survey
Survey
VHA Generic Request: VA Form 10-0527, VA PVAMC Low Vision
Notice Nurse Comment Form 10-0528, VA form Patient Satisfaction
Card; Low Vision Clinic 10-0519
Survey, Vendor
Patient Satisfaction
Application for Fair, Notice
Survey; Vendor
Your Nurse
Registration; Telephone
Transformation Focus
Group
PACT Lab Caregiver
Article and Volume
Office of Public Health
and Patient Focus
Number of Newsletter, Gulf War Newsletter
Groups; Point of Care VA Form 10-0526
Survey, The Continuity of
(POC) Patient and
Medication Management
Provider Focus Groups;
Patient Survey
Telehealth in the
PADRECC: Veteran
Focus Group; COMM
Patient Survey; Office of
Public Health Survey
Childcare Service
VA Form 10-0540, VA Teleretinal Patient
Satisfaction Survey;
Form 10-0538, VA Form Satisfaction Survey,
Purchased Care Online 10-0542, VA Form 10- Purchased Care Patient
Survey; VHA ORD
0531
Satisfaction Survey,
Focus Group Request;
Spinal Cord Home Care
Teleretinal Patient
Survey, Childcare
Satisfaction Survey;
Services Satisfaction
Spinal Cord Home Care
Survey
Satisfaction Survey
Spinal Cord Patient
VA Form 10-0546, VA
5 CFR 1320.9
Survey; Caregiver
Form 10-0545, VA Form
Training Participant
10-0541, VA Form 10Feedback; Income
0515, VA Form 10-0520
Verification Survey;
Non-VA Care Vet
Survey; Neuro-Rehab
Satisfaction Survey
Community Living
VA Form 10-0550, VA Psychiatric Patient
5 CFR 1320.8(d)
Center (CLC)
Form 10-0547, VA Form Satisfaction Survey,
Satisfaction Survey;
10-0548
Cardiac Cath Lab
Cardiac Cath Lab
Customer Satisfaction
Satisfaction Survey;
Survey, Community Living
Psychiatric Patient
Center (CLC) Satisfaction
Survey
Survey

Hrs/$/Resp
1,281 / 0 / 13,482

125 / 0 / 2,500

80 / 0 / 1,600

55 / 0 / 220

1,440 / 0 / 7,200

126 / 0 / 586

1,165 / 0 / 11,356

1,883 / 0 / 30,875

1,335 / 0 / 12,920

64 / 0 / 875

IC Title
Survey of Veterans
Perceptions of an
Enhanced VA
Outpatient Prescription
Label
VCS Patriot Store/Cafe
Customer/VCS Focus
Group/Patient
Experience of Care
Survey/VA Dental
Service Customer
Survey/Mental Health
Satisfaction

PTSD Family Caregiver
Feedback/ARCH Focus
Group/VA Courtesy
Standards/PTSD Coach
(Phone) Apps Survey

Food and Nutrition
Survey/Fraud,Waste,Ab
use Complaint/Epilepsy
Satisf-Survey/Building
Better Caregivers
Survey/Sodium
Dichromate Feedback
Survey

Form No.
VA Form 10-0549

List of ICs
Form Name

CFR Citation

Rx Label Feedback

VA form 10-0553, VA
Form 10-0554, VA form
10-0552, VA Form 100553S, VA Form 100551

Dental Service Customer
Satisfaction Survey, Office
of Mental Health Veteran
Satisfaction Survey,
Patient Experience of
Care Survey, Dental
Satisfaction Survey
(Spanish version), VCS
Patriot Store and VCS
Patriot Cafe Customer
Satisfaction Survey
VA Form 10-0497, VA VA Courtesy Standards - 5 CFR 1320.8(d)
Form 10-0496a, VA
The Golden Rule
Form 10-0496, VA Form Approach Veteran
10-0495
Feedback Form, Phone
Apps Focus Group
Demographic
Questionnaire, PTSD
Coach App Survey,
Understanding PTSD for
Family Caregivers:
Feedback Survey
VA Form 10-0499, VA Building Better Caregivers 5 CFR 1320.8(d)
Form 10-0558, VA Form Satisfaction Survey,
10-0500, VA Form 10- Epilepsy Centers of
0498, VA Form 10-0559 Excellence (ECoE) Patient
Satisfaction Survey,
Fraud, Waste and Abuse
Complaint Form, Food
and Nutrition Satisfaction
Survey, Sodium
Dichromate Exposure
Exam Feedback Survey
5 CFR 1230.8(d)

VHA Customer Value
Online Survey /
Customer Value Focus
Group
Vet Apptmnt Apps
Satisfaction Srvy/HemOncology Telehealth
Satisfaction Svy
DeBakey Home Care
VA Form 10-0480, VA
Satisfaction Survey /
Form 10-0476
CPEP Veterans
Satisfaction Survey

Compensation and
Pension Examination
Program (CPEP) Veterans
Satisfaction Survey,
Michael E. DeBakey
Patient Satisfaction
Survey
Patient Satisfaction
VA Form 10-10063, VA Patient Satisfaction
Surveys: Radiation
Form 10-10058
Survey- Radiation
Oncology/VISN 12
Oncology, Telephone
Telephone Care Service
Care Services Patient
Satisfaction Survey
Boston VAMC
VA Form 10-10059, VA Telephone Customer
Ophthamology
Form 10-211001NR
Service Experience
Satisfaction Survey /
Satisfaction Survey,
VISN 20 Telephone Call
Patient Satisfaction
Center Satisfaction
Survey_Boston
Survey
VAMC_Dept. of
Ophthamology

Hrs/$/Resp
373 / 0 / 5,600

2,632 / 0 / 11,765

1,353 / 0 / 4,420

4,941 / 0 / 129,980

423 / 0 / 860

36 / 0 / 430

170 / 0 / 1,714

66 / 0 / 560

275 / 0 / 2,300

IC Title
Anticoagulation
(Warfarin/Coumadin)
Patient Satisfaction
Survey
MSCoE Patient
Survey/Project ARCH
Non-Participant
Survey/Wait Rm
Television Edu Survey

Form No.
VA Form 10-211002

List of ICs
Form Name

CFR Citation

Anticoagulation
(warfarin/Coumadin)
Patient Satisfaction
Survey
VA Form 10-211005,
Patient Survey: Waiting
VA Form 10-211003,
Room Television Video
VA Form 10-211004
Patient Education,
MSCoE Patient Survey,
PROJECT ARCH (Access
Received Closer to Home)
Non-Participating
Veterans Survey
Outpatient Pharmacy
VA Fform 10-211006NR Outpatient Pharmacy
5 CFR 1320.9
Customer Satisfaction
Customer Satisfaction
Survey
Survey
National Patient
10-211009, 10-211008 National Patient Centered
Centered Community
Community Care Veterans
Care Survey Questions
Survey Question, Dental
/ Oklahoma City (OKC)
(Ambulatory) Patient
VAMC Dental Patient
Satisfaction Survey
Satisfaction Survey
Rehabilitation Care
VA Form 10-211004,
Project ARCH NonSurvey/HEC Vet
VA Form 10-211013,
Participant Survey, HEC
Enrollment
VA Form 10-211010
Enrollment Survey,
Survey/Project ARCH
Survey of Rehabilitation
non-sub change
Care Survey
HomeBased
VA Form 10-211013,
Non-VA-Purchased Care
PrimaryCare
VA Form 10-211016,
Veteran Survey, TeleSurvey/Non-VA
VA Form 10-211014,
Dermatology Imaging
Purchased Care
VA Form 10-211011
Patient Satisfaction
Survey/Vet Dental
Survey, Home Based
Insurance
Primary Care Survey,
Survey/Teledermatolog
Dental Insurance Program
y Imaging Patient
Survey
Satisfaction Survey
Survey of Patient
VA Form 10-211015,
Survey of Patient
Satisfaction at Surgical VA Form 10-211015SP Satisfaction at Surgical
Service
Service, Spanish version:
Survey of Patient
Satisfaction at Surgical
Services
VISN 1 Call Center
VA Form 10-211014a
Customer Service
Survey / OKC HB
Primary Care
Satisfaction Survey
2014 Post-9/11 GI Bill
Communications
Assessment
Mental Health Survey, 10-10125, 10-10126,
Prosthetics Customer
Prosthetics Customer 10-10122, 10-10123
Service Survey, Patient
Service Survey,
Satisfaction Survey, HME
Prosthetics Internal
Vendor Performance
Survey, HME Survey
Survey, MH Veteran
Survey
Awards and ROI-2013 2900-0770, 2900-0770 Awards and ROI - 2013
NVSBC
NVSBC, Awards and ROI2013 NVSBC
OSDBU Post-Event
2900-0770
OSDBU Post-Event
Evaluation
Evaluation
OPA Patient
10-10127, 10-10128,
Telehealth Master
Satisfaction, Audiology 10-0526, 10-10129
Preceptor, Audiology
Survey, National Rollout
Hearing Aid Questionaire,
Survey, Telehealth
Caribean Harvey Survey,
Survey
Mental Health Survey

Hrs/$/Resp
560 / 0 / 4,800

1,866 / 0 / 7,515

4 / 0 / 50
1,434 / 0 / 12,400

271 / 0 / 1,328

1,388 / 0 / 14,320

608 / 0 / 1,825

314 / 0 / 4,350

75 / 0 / 100
1,317 / 0 / 3,160

89 / 0 / 1,639
542 / 0 / 10,000
0 / 0 / 10,366

IC Title
VA Office of
Construction and
Facilities Management
(CFM) Supplier
Satisfaction Survey
Revision
2014 NVSBE Events
Satisfaction

Form No.
VA Form 10163

List of ICs
Form Name

CFR Citation

CFM Supplier Satisfaction
Survey

2900-0770, 2900-0770, Exhibitor Satisfaction,
2900-0770, 2900-0770, Business Requirement
2900-0770, 2900-0770 Sessions, CVE Booth
Satisfaction, Senior
Leaders Roundtables ,
Learning Sessions, NRT
Satisfaction
2014 NVSBE Post2900-0770
2014 NVSBE PostEngagement
Engagement Survey
Total Hours Actually Used for Information Collections Under Currently Approved ICR:

Hrs/$/Resp
183 / 0 / 1,000

541 / 0 / 16,225

15 / 0 / 3,500
27,030