Information Collection

2019 024 My HealtheVet Feedback Survey

IC 235687 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 024 2019 024 My HealtheVet Feedback Survey Form and Instruction
024 2019 024 My HealtheVet Feedback Survey 2019 024 My HealtheVet Feedback Survey.xlsx Form and Instruction
1090-0008 Generic Clearance Request Form My HealtheVet Feedback.pdf 1090-0008 Generic Clearance Request Form My HealtheVet Feedback IC Document
1090-0008 Survey Mapping Document My HealtheVet.docx 1090-0008 Survey Mapping Document My HealtheVet IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	2019 024 My HealtheVet Feedback Survey	Agency IC Tracking Number:	024

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	024	2019 024 My HealtheVet Feedback Survey	2019 024 My HealtheVet Feedback Survey.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 %

	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

Title	Document	Date Uploaded
1090-0008 Generic Clearance Request Form My HealtheVet Feedback	1090-0008 Generic Clearance Request Form My HealtheVet Feedback.pdf	04/16/2019
1090-0008 Survey Mapping Document My HealtheVet	1090-0008 Survey Mapping Document My HealtheVet.docx	04/16/2019

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