Information Collection

CXPA Veteran Enrollment Survey

IC 274692 under ICR 202503-2900-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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 CXPA Vet CXPA Veteran Enrollment Survey CXPA Veteran Enrollment Survey	Form and Instruction
2900-0876 CXPA Vet CXPA Veteran Enrollment Survey VES Wireframe 3.17.25.docx	Form and Instruction
A11 Fast-Track Clarance Request Template_CXPA_VES Survey.docx CXPA Veteran Enrollment Survey	IC Document

IC Title:

CXPA Veteran Enrollment Survey

Agency IC Tracking Number:

2900-0876 CXPA Veteran Enrollment Survey

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 CXPA Veteran Enrollment Survey				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Veterans, Dependents of Veterans, and VA Beneficiary Survey Records

FR Citation: 43 FR 8

Number of Respondents: 2,000

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	2,000	2,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CXPA Veteran Enrollment Survey		04/03/2025

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

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