VA VHA CHAMPVA Beneficiaries Survey #1-20923 A0

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⚠️ Notice: This information collection may be referencing outdated material.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 073-20923A0 VA VHA CHAMPVA Beneficiaries Survey #1-20923 A0 Form and Instruction
073-20923A0 VA VHA CHAMPVA Beneficiaries Survey #1-20923 A0 CHAMPVA Survey 2019_FINAL.docx Form and Instruction
Generic Clearance Request Form_CHAMPVA 2019-signed.pdf Generic Clearance Request Form IC Document
OMB Mapping Cover_CHAMPVA 2019.xlsx OMB Mapping Cover IC Document

Information Collection (IC) Details

IC Title:	VA VHA CHAMPVA Beneficiaries Survey #1-20923 A0	Agency IC Tracking Number:	073-20923A0

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	073-20923A0	VA VHA CHAMPVA Beneficiaries Survey #1-20923 A0	CHAMPVA Survey 2019_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_CHAMPVA 2019-signed.pdf	12/19/2019
OMB Mapping Cover	OMB Mapping Cover_CHAMPVA 2019.xlsx	12/19/2019

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