Information Collection

Ethics Consultation Feedback Tool

IC 192020 under ICR 201709-2900-016 · OMB 2900-0750.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-10065 Ethics Consultation Feedback Tool	Form
VA Form 10-10065 Ethics Consultation Feedback Tool VA Form 10-10065.pdf	Form

IC Title:

Agency IC Tracking Number:

2900-0750

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 10-10065	Ethics Consultation Feedback Tool	VA Form 10-10065.pdf	ECWeb	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 569

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	569	365	204
Annual IC Time Burden (Hours)	47	30	17
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.