Information Collection

30715 2021 Proposed-Revision_VHA_Medical_Centers_Questionnaire Nov_3_2021

IC 250368 under ICR 202109-1090-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 30715 2021 Proposed-Revision_VHA_Medical_Centers_Questionnaire Nov_3_2021	Form and Instruction
30715 30715 2021 Proposed-Revision_VHA_Medical_Centers_Questio 30715 2021 Proposed-Revision_VHA_Medical_Centers_Questionnaire Nov_3_2021.xlsx	Form and Instruction
Mapping Doc_VHA Medical Centers_Nov 4 2021 (002).docx Mapping Doc_VHA Medical Centers_Nov 4 2021 (002)	IC Document
Signed 1090-0008 Generic Clearance Request Form_VHA Medical Centers_Nov 5 2021.pdf Signed 1090-0008 Generic Clearance Request Form_VHA Medical Centers_Nov 5 2021	IC Document

IC Title:

30715 2021 Proposed-Revision_VHA_Medical_Centers_Questionnaire Nov_3_2021

Agency IC Tracking Number:

30715 2021

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	30715 2021 Proposed-Revision_VHA_Medical_Centers_Questionnaire Nov_3_2021	30715 2021 Proposed-Revision_VHA_Medical_Centers_Questionnaire Nov_3_2021.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: 2,670

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	2,670	2,670
Annual IC Time Burden (Hours)	178	178
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Mapping Doc_VHA Medical Centers_Nov 4 2021 (002)	Mapping Doc_VHA Medical Centers_Nov 4 2021 (002).docx	11/16/2021
Signed 1090-0008 Generic Clearance Request Form_VHA Medical Centers_Nov 5 2021	Signed 1090-0008 Generic Clearance Request Form_VHA Medical Centers_Nov 5 2021.pdf	11/16/2021

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