Information Collection

30715 2021 Proposed-Revision_VHA_Medical_Centers_Questionnaire Nov_3_2021

IC 250368 under ICR 202204-1090-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
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
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
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: Unchanged

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
	Requested	Previously Approved
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.