Information Collection

Emergency Medicine Customer Satisfaction Survey

IC 241506 under ICR 202003-2900-011 · OMB 2900-0876.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0876 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2900-0876-002 Emergency Medicine Customer Satisfaction Survey	Form and Instruction
2900-0876-002 Emergency Medicine Customer Satisfaction Survey EM Survey Mockups_Web Page V7.2.pdf va.voice.va.gov/sso/va	Form and Instruction
A-11 Fast-Track Clearance Request Template_EM_(004).docx Request Form	IC Document
Emergency Medicine Sampling Plan.docx Sampling Methodology	IC Document

IC Title:

Emergency Medicine Customer Satisfaction Survey

Agency IC Tracking Number:

VEO00001

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	2900-0876-002	Emergency Medicine Customer Satisfaction Survey	EM Survey Mockups_Web Page V7.2.pdf	https://va.voice.va.gov/sso/va	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 208,000

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	208,000	208,000
Annual IC Time Burden (Hours)	10,400	10,400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request Form	A-11 Fast-Track Clearance Request Template_EM_(004).docx	04/23/2020
Sampling Methodology	Emergency Medicine Sampling Plan.docx	04/23/2020

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