Information Collection

2018 005 VA MOVE! Patient Experience Survey 2018

IC 233385 under ICR 201805-1090-002 · OMB 1090-0007.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1090-0007 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 005-20321 A0 2018 005 VA MOVE! Patient Experience Survey 2018	Form and Instruction
005-20321 A0 VA MOVE! Patient Experience Survey-005-20321 A0 VA MOVE! Patient Experience Survey_FINAL_IA 20321.docx	Form and Instruction
1090-0007 Generic Clearance Request Form VA MOVE_IA 20321 A0-.pdf 2018 005 VA MOVE! Patient Experience Survey 2018	IC Document
OMB Mapping VA MOVE Patient Experience Survey 20321 A0.xlsx 2018 005 VA MOVE! Patient Experience Survey 2018	IC Document

IC Title:

2018 005 VA MOVE! Patient Experience Survey 2018

Agency IC Tracking Number:

005-20321 A0

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
Form and Instruction	005-20321 A0	VA MOVE! Patient Experience Survey-005-20321 A0	VA MOVE! Patient Experience Survey_FINAL_IA 20321.docx		Yes	Yes	Fillable Printable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
2018 005 VA MOVE! Patient Experience Survey 2018	1090-0007 Generic Clearance Request Form VA MOVE_IA 20321 A0-.pdf	10/03/2018
2018 005 VA MOVE! Patient Experience Survey 2018	OMB Mapping VA MOVE Patient Experience Survey 20321 A0.xlsx	10/03/2018

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