Emergency Medicine Customer Satisfaction Survey

Clearance for A-11 Section 280 Improving Customer Experience Information Collection

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Emergency Medicine Customer Satisfaction Survey	Agency IC Tracking Number:	VEO00001

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	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 %

	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

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.