Information Collection

Mapping and Questionnaire Documents IA 30715 A2 (VHA)

IC 235201 under ICR 201805-1090-003 · OMB 1090-0008.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1090-0008 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 30715 Mapping and Questionnaire Documents IA 30715 A2 (VHA)	Form and Instruction
30715 VHA_Medical_Centers_Questionnaire Redesign Questions 12- VHA_Medical_Centers_Questionnaire Redesign Questions 12-14-2017_DOT.xlsx	Form and Instruction
1090-0008 Survey Mapping Document (VHA) IA 30715 A2_draft.xlsx 1090-0008 Survey Mapping Document (VHA) IA 30715 A2_draft	IC Document
VHA OMB Form 11.13.2018 IA 30715 A2.pdf VHA OMB Form 11.13.2018 IA 30715 A2	IC Document

IC Title:

Mapping and Questionnaire Documents IA 30715 A2 (VHA)

Agency IC Tracking Number:

30715 A2

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	30715	VHA_Medical_Centers_Questionnaire Redesign Questions 12-14-2017_DOT	VHA_Medical_Centers_Questionnaire Redesign Questions 12-14-2017_DOT.xlsx		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,600

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	3,600	3,600
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
1090-0008 Survey Mapping Document (VHA) IA 30715 A2_draft	1090-0008 Survey Mapping Document (VHA) IA 30715 A2_draft.xlsx	03/06/2019
VHA OMB Form 11.13.2018 IA 30715 A2	VHA OMB Form 11.13.2018 IA 30715 A2.pdf	03/06/2019

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