VHA Inpatient Customer Satisfaction Survey

American Customer Satisfaction Index "Customer Satisfaction Surveys"

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 037 VHA Inpatient Customer Satisfaction Survey Form and Instruction
037 NHA inpatient Customer Satisfaction Survey VHA_Inpatient 2018 Survey Final.docx Form and Instruction
Generic Clearance Request Form_VA Inpatient IA 20805 A0.pdf Generic Clearance Request Form IC Document
OMB Mapping Cover VA Inpatient IA 20805 A0 (1).xlsx Mapping Cover VHA Inpatient IC Document

Information Collection (IC) Details

IC Title:	VHA Inpatient Customer Satisfaction Survey	Agency IC Tracking Number:	037

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	037	NHA inpatient Customer Satisfaction Survey	VHA_Inpatient 2018 Survey Final.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 %

	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

Title	Document	Date Uploaded
Generic Clearance Request Form	Generic Clearance Request Form_VA Inpatient IA 20805 A0.pdf	10/11/2018
Mapping Cover VHA Inpatient	OMB Mapping Cover VA Inpatient IA 20805 A0 (1).xlsx	10/11/2018

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