Information Collection

VHA Outpatient Customer Satisfaction Survey

IC 233481 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⚠️ Notice: This information collection may be referencing outdated material.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 038 VHA Outpatient Customer Satisfaction Survey	Form and Instruction
038 VHA Outpatient Customer Satisfaction Survey VHA_Outpatient 2018 Survey Final.docx	Form and Instruction
Generic Clearance Request Form_VA Outpatient IA 20805 A0.pdf Generic Clearance Request Form	IC Document
OMB Mapping Cover VA Outpatient IA 20805 A0 .xlsx Mapping Cover VHA Outpatient	IC Document

IC Title:

VHA Outpatient Customer Satisfaction Survey

Agency IC Tracking Number:

038

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	038	VHA Outpatient Customer Satisfaction Survey	VHA_Outpatient 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 %

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
Generic Clearance Request Form	Generic Clearance Request Form_VA Outpatient IA 20805 A0.pdf	10/11/2018
Mapping Cover VHA Outpatient	OMB Mapping Cover VA Outpatient IA 20805 A0 .xlsx	10/11/2018

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