Information Collection

VA VHA CHAMPVA Beneficiaries Survey #1-20923 A0

IC 239002 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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	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 %

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_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.