Information Collection

VA Pittsburgh Community Nursing Home Satisfaction Survey

IC 228699 under ICR 201710-2900-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Patient Satisfaction Survey w cover - VA Pittsburgh 646 - Community Nursing Home.doc	Other-Satisfaction Survey
Clearance submission template - VHA Pittsburgh 646 - CNH Program.docx Generic Request - VA Pittsburgh_CNH	IC Document

IC Title:

VA Pittsburgh Community Nursing Home Satisfaction Survey

Agency IC Tracking Number:

2900-0770

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Satisfaction Survey			Patient Satisfaction Survey w cover - VA Pittsburgh 646 - Community Nursing Home.doc		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 120

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	120	120
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Request - VA Pittsburgh_CNH	Clearance submission template - VHA Pittsburgh 646 - CNH Program.docx	10/18/2017

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