Information Collection

Amputation System of Care Veteran Experience Survey

IC 278843 under ICR 202508-2900-010 · OMB 2900-0876.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Amputation System of Care Survey Wireframe_new.docx	Other-Survey Instrument
A-11 Fast-Track Clearance Request Template 2025-12-17 (Amputation System of Care).docx A-11 Fast Track Clearance Template Amputation System of Care	IC Document

IC Title:

Agency IC Tracking Number:

2900-0876 amputation

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: 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
A-11 Fast Track Clearance Template Amputation System of Care		01/22/2026

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

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