NOA VE Feedback 2017

NOTICE OF OFFICE OF MANAGEMENT AND BUDGET ACTION
Date

03/27/2017

Department of Veterans Affairs

FOR CERTIFYING OFFICIAL:

Rob Thomas

FOR CLEARANCE OFFICER:

Cynthia Harvey-Pryor

In accordance with the Paperwork Reduction Act, OMB has taken action on your request received
03/27/2017
ACTION REQUESTED: Generic IC
VE Feedback Tool: eComment Card
IC TITLE:
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: 08/31/2017

BURDEN:

DISCONTINUE DATE:

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
Deputy and Acting 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 Nuerology/Rehabilitation 5 CFR 1320.9
Survey; Caregiver
Form 10-0545, VA Form Inpatient Program
Training Participant
10-0541, VA Form 10- Satisfaction Survey, NonFeedback; Income
0515, VA Form 10-0520 VA Care Coordination
Verification Survey;
Veteran Satisfaction
Non-VA Care Vet
Survey, Survey of
Survey; Neuro-Rehab
Veterans' Satisfaction with
Satisfaction Survey
Income Verification,
Spinal Cord Injury Patient
Survey, National Family
Caregiver Participant
Training Feedback Form

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

IC Title
Community Living
Center (CLC)
Satisfaction Survey;
Cardiac Cath Lab
Satisfaction Survey;
Psychiatric Patient
Survey
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.

List of ICs
Form Name

CFR Citation

Hrs/$/Resp

VA Form 10-0550, VA Psychiatric Patient
5 CFR 1320.8(d)
Form 10-0547, VA Form Satisfaction Survey,
10-0548
Cardiac Cath Lab
Customer Satisfaction
Survey, Community Living
Center (CLC) Satisfaction
Survey
VA Form 10-0549
Rx Label Feedback

64 / 0 / 875

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

2,632 / 0 / 11,765

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

373 / 0 / 5,600

1,353 / 0 / 4,420

4,941 / 0 / 129,980

423 / 0 / 860

36 / 0 / 430

170 / 0 / 1,714

66 / 0 / 560

IC Title

Form No.

Boston VAMC
VA Form 10-10059, VA
Ophthamology
Form 10-211001NR
Satisfaction Survey /
VISN 20 Telephone Call
Center Satisfaction
Survey

List of ICs
Form Name

CFR Citation

Telephone Customer
Service Experience
Satisfaction Survey,
Patient Satisfaction
Survey_Boston
VAMC_Dept. of
Ophthamology
Anticoagulation
VA Form 10-211002
Anticoagulation
(Warfarin/Coumadin)
(warfarin/Coumadin)
Patient Satisfaction
Patient Satisfaction
Survey
Survey
MSCoE Patient
VA Form 10-211005,
Patient Survey: Waiting
Survey/Project ARCH VA Form 10-211003,
Room Television Video
Non-Participant
VA Form 10-211004
Patient Education,
Survey/Wait Rm
MSCoE Patient Survey,
Television Edu 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 10-211015SP, Spanish version: Survey
Satisfaction at Surgical VA Form 10-211015
of Patient Satisfaction at
Service
Surgical Services, Survey
of Patient Satisfaction at
Surgical Service
VISN 1 Call Center
VA Form 10-211014a Oklahoma City VAMC
Customer Service
Home Based Primary
Survey / OKC HB
Care (HBPC) Program
Primary Care
Satisfaction Survey
2014 Post-9/11 GI Bill
Communications
Assessment
Mental Health Survey, 10-10123, 10-10122,
MH Veteran Survey, HME
Prosthetics Customer 10-10126, 10-10125
Vendor Performance
Service Survey,
Survey, Patient
Prosthetics Internal
Satisfaction Survey,
Survey, HME Survey
Prosthetics Customer
Service 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

Hrs/$/Resp
275 / 0 / 2,300

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

IC Title

Form No.

Health Research
10-10145, 2900-0770,
Multilevel Engagement, 10-10142, 10-10147
SORCC Patient Survey,

OPA Patient
10-10128, 10-10127,
Satisfaction, Audiology 10-10129, 10-0526
Survey, National Rollout
Survey, Telehealth
Survey
VA Office of
VA Form 10163
Construction and
Facilities Management
(CFM) Supplier
Satisfaction Survey
Revision
Extended Hours
10-10144, 10-10132,
Program Evaluation,
10-10131, 10-10128,
Maternity Care
10-10136, 10-10129
Coordination, Advanced
Education Veteran
Survey, State Veterans
Home Administrator
Survey, VOV Conjoint
Survey

List of ICs
Form Name
SOU-SORCC Patient
Survey, State Veterans
Home Patient Satisfaction,
Womens Health Research
Network , VHA OSI
Primary Care Survey
Audiology Hearing Aid
Questionaire, Telehealth
Master Preceptor, Mental
Health Survey, Caribean
Harvey Survey
CFM Supplier Satisfaction
Survey

Voice of the Veteran
(VOV) Satisfaction Survey
Office of Strategic
Integration (OSI) Conjoint
Analysis, Extended Hours
Evaluation - Users,
Maternity Care
Coordination Survey,
Advanced Education
Veteran Survey, State
Veterans Home Admin
Survey, Extended Hours
Evaluation - Non-Users
IOM Study, NCL Patient 10-10133, 10-10131,
VISN 1 Patient
Satisfaction Survey,
10-10128, 10-10130,
Satisfaction Survey, IOM
Battlecreek Urgent Care 10-10135, 10-10136
VA Mental Health
Survey, Tobacco &
Services Evaluation, IOM
Nicotine Use Survey,
VA Mental Health
VISN 1 Patient
Services Evaluation, IOM
Satisfaction Survey
VA Mental Health
Services Evaluation,
Battlecreek Urgent Care
Survey, Tobacco and
Smoking Cessation
Survey
2014 NVSBE Events
2900-0770, 2900-0770, Senior Leaders
Satisfaction
2900-0770, 2900-0770, Roundtables , Exhibitor
2900-0770, 2900-0770 Satisfaction, CVE Booth
Satisfaction, Learning
Sessions, NRT
Satisfaction, Business
Requirement Sessions
2014 NVSBE Post2900-0770
2014 NVSBE PostEngagement
Engagement Survey
MHV Website
10-10114, 10-10119,
National Family Caregiver
Redesign, National
10-10155
Participant Training
Family Caregiver
Feedback Form,
Survey, MEC
Caregiver Feedback
Notification Survey
Form, MEC Notification
Survey
Veterans Choice
10-0552, 10-0450, 10- Patient Experience of
Program, Nationwide
0455, 10-0457
Care Survey, Veterans
Dialysis Contracts,
Choice Program Survey,
VLER User Survey,
Nationwide Dialysis
Healthcare User survey,
Program Survey, VLER
Patient Experience of
Program Survey
Care
NAC Customer
Response Survey

CFR Citation

Hrs/$/Resp
1,067 / 0 / 4,477

0 / 0 / 10,366

183 / 0 / 1,000

521 / 0 / 1,840

897 / 0 / 2,990

541 / 0 / 16,225

15 / 0 / 3,500
5,084 / 0 / 42,029

1,339 / 0 / 10,045

83 / 0 / 1,000

IC Title

Form No.

List of ICs
Form Name

CFR Citation

PIM Patient INterview
Guide, PIM Patient Letter,
PIM Stakeholder
Interview, VPS Survey
Questions, Watson's
Caritas Patient Survey
VA Form 10-10167, VA Customer Satisfaction
Form 10-10164
Survey on VA Research
Communication, VA
Research Currents, VISN
20 Cancer Care Survey

Hrs/$/Resp

CBO-Veterans Point of 10-10169, 10-10168,
Service; PACT
10-10170, 10-10171,
Intensive Management 10-10172
Evaluation; Watson
Caritas Patient Score

467 / 0 / 5,350

VISN 20 Cancer Care
Survey, VA Research
Currents

260 / 0 / 3,204

Customer Satisfaction
Survey for Claims
Clinics Pilot Program
VHA Women Veterans
Call Center
Feedback USA Button

5 CFR 1320.9

333 / 0 / 2,000
8,667 / 0 / 130,000

5 CFR 1320.9

VA Conjoint Survey 10-1500188(WS)
External
Communication
Health Advocate Survey

VA External
Communication Conjoint
Questionnaire

128 / 0 / 1,920
200 / 0 / 800
4 / 0 / 50

Telebenefits
Satisfaction Survey
Health Advocate Survey

667 / 0 / 4,000

Veteran Experience and
Satisfaction with the
Department of Veteran
Affairs Compensation
and Pension Claims
Examination
Cooperative Studies
10-1500196(WS), 10Program
1500197(WS)

833 / 0 / 10,000

21 / 0 / 250

Clinic Based Telehealth 10-0481a
Satisfaction Survey
Veterans Experience
10-0516, 10-0476
Initiative
VAInfoApp
Shared Decision
Making
Rehabilitation and
Audiology Customer
Service Survey
Non-VA Behavioral
Health Care
HRC Satisfaction
Survey
VACT Primary Care
Patient Satisfaction
Questionnaire
Verification Cost of
Compliance
Veteran Experience and
Satisfaction with the
Department of Veterans
Affairs Compensation
and Pension Claims
Examination Survey
Mental Health - SORCC
Satisfaction Survey

10-1500199(WS)

DMC Survey, CSPCC
Study Chairperson and
NSC Survey
VA Telehealth Patient
Survey
NCL Patient Satisfaction
Questionnaire , Michael E.
DeBakey Home Care
Program
MySurvey

9 / 0 / 105
2,500 / 0 / 10,000
8,185 / 0 / 491,126

15 / 0 / 30
25 / 0 / 150
60 / 0 / 240
25 / 0 / 150
1,750 / 0 / 35,000
100 / 0 / 400
15 / 0 / 150
1,167 / 0 / 10,000

83 / 0 / 2,500

IC Title
Survey regarding
effectiveness of the GI
Bill Feedback System
VAR Mobile App
Rev_8-2016
Primary Care
Satisfaction and
Effectiveness Survey
Debt Management
Center - Customer
Service Experience
VE Access Survey
Questions
Community Residential
Care
MFH Caregiver Survey

Form No.

List of ICs
Form Name

CFR Citation
5 CFR 1320.9

Hrs/$/Resp
0 / 0 / 250
38 / 0 / 25
33 / 0 / 1,000
1,800 / 0 / 18,000
833 / 0 / 50,000
267 / 0 / 3,200
58 / 0 / 700

MFH Veteran Survey

83 / 0 / 1,000

CWT IT Consumers
Satisfaction Survey_1
CWT IT Stakeholders
Satisfaction Survey
CWT TW Consumers
Satisfaction Survey
MHICM Consumer
Satisfaction Survey
PTSD Consultation
Program
VCP_VACC Provider
10-1500210(WS), 10- VACC Provider Survey,
Survey
1500209(WS)
VCP Provider Survey
Congressional
Response Team
Customer Satisfaction
Survey
Admission Process
Customer Satisfaction
Survey - Roseburg
VAMC
Veterans Affairs
Acquisition 360 Survey
Board of Veterans
Appeals Hearing
Experience Surveys
VE Feedback Tool:
eComment Card
Total Hours Actually Used for Information Collections Under Currently Approved ICR:

20 / 0 / 120
2 / 0 / 10
23 / 0 / 140
10 / 0 / 60
200 / 0 / 1,200
667 / 0 / 4,000
9 / 0 / 110

25 / 0 / 304

105 / 0 / 420
917 / 0 / 8,000
11 / 0 / 135
66,636