Information Collection

Outpatient-Healthcare Visit-Adding Whole Health Questions

IC 278724 under ICR 202508-2900-010 · OMB 2900-0876.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Outpatient Health Care Visit - Adding Whole Health Questions.docx	Other-Survey Instrument
ICR Template_A11 Section 280 Clearance Outpatient Healthcare Visit Adding Whole Health Questions.docx ICR Template A11 Section 280 Clearance Outpatient Healthcare Visit Adding Whole Health Questions	IC Document

IC Title:

Agency IC Tracking Number:

2900-0876

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
Other-Survey Instrument					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Veterans, Dependents of Veterans, and Veteran Beneficiaries

FR Citation: 86 FR 6992

Number of Respondents: 5,000

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	5,000	5,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ICR Template A11 Section 280 Clearance Outpatient Healthcare Visit Adding Whole Health Questions		01/12/2026

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

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