Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)

Forms and Documents

Document Name	Status
Form 10-1500210(WS) VCP_VACC Provider Survey Form and Instruction	New
Form 10-1500199(WS) VAInfoApp Form and Instruction	New
Form 10-0516 Veterans Experience Initiative Form and Instruction	New
Form 10-0481a Clinic Based Telehealth Satisfaction Survey Form and Instruction	New
Form 10-1500197(WS) Cooperative Studies Program Form	New
Form 10-1500188(WS) VA Conjoint Survey - External Communication Form and Instruction	New
Form VA Form 10-10164 VISN 20 Cancer Care Survey, VA Research Currents Form and Instruction	New
Form 10-10168 CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score Form and Instruction	New
Form 10-0450 Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care Form and Instruction	New
Form 10-10114 MHV Website Redesign, National Family Caregiver Survey, MEC Notification Survey Form and Instruction	New
Form 2900-0770 2014 NVSBE Post-Engagement Form	New
Form 2900-0770 2014 NVSBE Events Satisfaction Form and Instruction	New
Form 10-10128 IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction Survey Form and Instruction	New
Form 10-10129 Extended Hours Program Evaluation, Maternity Care Coordination, Advanced Education Veteran Survey, State Veterans Home Administrator Survey, VOV Conjoint Survey Form and Instruction	New
Form VA Form 10163 VA Office of Construction and Facilities Management (CFM) Supplier Satisfaction Survey Revision Form and Instruction	New
Form 10-0526 OPA Patient Satisfaction, Audiology Survey, National Rollout Survey, Telehealth Survey Form and Instruction	New
Form 10-10142 Health Research Multilevel Engagement, SORCC Patient Survey, Form and Instruction	New
Form 2900-0770 OSDBU Post-Event Evaluation Form	New
Form 2900-0770 Awards and ROI-2013 NVSBC Form	New
Form 10-10122 Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey Form and Instruction	New
Form VA Form 10-211015 Survey of Patient Satisfaction at Surgical Service Form	Modified
Form VA Form 10-211014 HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey Form	Modified
Form VA Form 10-211010 Rehabilitation Care Survey/HEC Vet Enrollment Survey/Project ARCH non-sub change Form	Modified
Form 10-211008 National Patient Centered Community Care Survey Questions / Oklahoma City (OKC) VAMC Dental Patient Satisfaction Survey Form	Modified
Form VA Fform 10-211006 Outpatient Pharmacy Customer Satisfaction Survey Form	Modified
Form VA Form 10-211003 MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey Form	Modified
Form VA Form 10-211002 Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey Form	Modified
Form VA Form 10-211001N Boston VAMC Ophthamology Satisfaction Survey / VISN 20 Telephone Call Center Satisfaction Survey Form	Modified
Form VA Form 10-10063 Patient Satisfaction Surveys: Radiation Oncology/VISN 12 Telephone Care Service Form	Modified
Form VA Form 10-0476 DeBakey Home Care Satisfaction Survey / CPEP Veterans Satisfaction Survey Form and Instruction	Modified
Form VA Form 10-0498 Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey Form	Modified
Form VA Form 10-0495 PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey Form	Modified
Form VA Form 10-0551 VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction Form	Modified
Form VA Form 10-0549 Survey of Veterans Perceptions of an Enhanced VA Outpatient Prescription Label Form	Modified
Form VA Form 10-0548 Community Living Center (CLC) Satisfaction Survey; Cardiac Cath Lab Satisfaction Survey; Psychiatric Patient Survey Form	Modified
Form VA Form 10-0515 Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey Form	Modified
Form VA Form 10-0531 Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey Form	Modified
Form VA Form 10-0527 VHA Generic Request: Notice Nurse Comment Card; Low Vision Clinic Patient Satisfaction Survey; Vendor Registration; Telephone Transformation Focus Group Form	Modified
Form VA Form 10-0522 Project ARCH (Access received Closer to Home) Patient Satisfaction Survey Form and Instruction	Modified
Form VA Form 10-0516 Patient Satisfaction Questionnaire: Network Consolidated Laboratory (NCL) Phlebotomy Service Form	Modified
Form VA Form 10-0481a Clinical Video Telehealth (CVT) Patient Satisfaction Survey Form	Modified
Form VA Form 10-0517 Veterans Transportation Service (VTS) Veterans Satisfaction Questionnaire Form	Modified
Correction to burden hours for 2900-0770.docx Justification for No Material/Nonsubstantive Change	2011-07-08
Generic Clearance Submission Template (2).doc Supplementary Document	2011-06-01
Qualitative Feedback Justification B.docx Supporting Statement B	2011-02-18
(NCA VBA VHA)-Qualitative_Feedback_Justification A.doc Supporting Statement A	2014-06-26

IC Document Collections

IC ID	Document Title	Status
227343	Veterans Experience Appointment Schedule Survey (Rev) Other-E-Survey	New
227225	Voice of the Customer Questionnaire for Pharmacy Choice Other-Telephone Survey	New
226882	VA Pittsburgh Health Care System Emergency Department Survey Other-Survey	New
226763	MHV Summative Test Other-Summative Test	New
226678	VA Pittsburgh Reseach Survey Other-Research Survey	New
226359	Veterans Experience Appointment Schedule Survey Other-eSurvey	New
226288	Mental Health - SORCC Other-Survey	New
226212	VE Feedback Tool: eComment Card Other-Web: eComment Card	New
226098	Board of Veterans Appeals Hearing Experience Surveys Other-Web Survey	New
225782	Supplier Perception Survey Other-Web Survey	New
225627	Veterans Millennium Act Emergency Care Benefit Satisfaction Survey Other-Survey	New
225430	Veterans Affairs Acquisition 360 Survey Other-Survey	New
225315	Admission Process Customer Satisfaction Survey - Roseburg VAMC Other-Survey	New
225033	Congressional Response Team Customer Satisfaction Survey Other-Survey	New
224796	VCP_VACC Provider Survey Form and Instruction	New
224294	PTSD Consultation Program Other-Feedback Survey	New
223683	MHICM Consumer Satisfaction Survey Other-Survey	New
223599	CWT TW Consumers Satisfaction Survey Other-Survey	New
223598	CWT IT Stakeholders Satisfaction Survey Other-Survey	New
223597	CWT IT Consumers Satisfaction Survey_1 Other-Survey	New
223588	MFH Veteran Survey Other-Survey	New
223587	MFH Caregiver Survey Other-Survey	New
223586	Community Residential Care Other-Survey	New
223381	VE Access Survey Questions Other-Email	New
223072	Debt Management Center - Customer Service Experience Other-Survey	New
223015	Primary Care Satisfaction and Effectiveness Survey Other-Questionnaire	New
222959	VAR Mobile App Rev_8-2016 Other-Study Plan	New
222462	Survey regarding effectiveness of the GI Bill Feedback System Other-Survey Instrument	New
222066	Mental Health - SORCC Satisfaction Survey Instruction	New
221904	Veteran Experience and Satisfaction with the Department of Veterans Affairs Compensation and Pension Claims Examination Survey Other-Survey	New
221798	Verification Cost of Compliance Other-Survey	New
221139	VACT Primary Care Patient Satisfaction Questionnaire Other-Questionnaire	New
220889	HRC Satisfaction Survey Other-Telephone Script	New
220703	Non-VA Behavioral Health Care Other-Survey	New
220699	Rehabilitation and Audiology Customer Service Survey Other-Telephone Script	New
220531	Shared Decision Making Other-Veteran Telephone Script	New
220440	VAInfoApp Form and Instruction	New
219472	Veterans Experience Initiative Form and Instruction	New
219448	Clinic Based Telehealth Satisfaction Survey Form and Instruction	New
219215	Cooperative Studies Program Form	New
219166	Veteran Experience and Satisfaction with the Department of Veteran Affairs Compensation and Pension Claims Examination Other-Exam survey screen shot of url	New
218997	Health Advocate Survey Other-Survey	New
218928	Telebenefits Satisfaction Survey Other-null	New
218847	Health Advocate Survey Other-Survey	New
218836	VA Conjoint Survey - External Communication Form and Instruction	New
218523	Feedback USA Button Other-Feed Back Button	New
218519	VHA Women Veterans Call Center Other-Survey Script	New
218510	Customer Satisfaction Survey for Claims Clinics Pilot Program Other-survey	New
218501	VISN 20 Cancer Care Survey, VA Research Currents Form and Instruction	New
217630	CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score Form and Instruction	New
216363	NAC Customer Response Survey Other-Web Based	New
215611	Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care Form and Instruction	New
214681	MHV Website Redesign, National Family Caregiver Survey, MEC Notification Survey Form and Instruction	New
214097	2014 NVSBE Post-Engagement Form	New
213869	2014 NVSBE Events Satisfaction Form and Instruction	New
213756	IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction Survey Form and Instruction	New
213752	Extended Hours Program Evaluation, Maternity Care Coordination, Advanced Education Veteran Survey, State Veterans Home Administrator Survey, VOV Conjoint Survey Form and Instruction	New
213502	VA Office of Construction and Facilities Management (CFM) Supplier Satisfaction Survey Revision Form and Instruction	New
213368	OPA Patient Satisfaction, Audiology Survey, National Rollout Survey, Telehealth Survey Form and Instruction	New
213210	Health Research Multilevel Engagement, SORCC Patient Survey, Form and Instruction	New
212980	OSDBU Post-Event Evaluation Form	New
212897	Awards and ROI-2013 NVSBC Form	New
212767	Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey Form and Instruction	New
212045	2014 Post-9/11 GI Bill Communications Assessment Other-Survey	New
210436	VISN 1 Call Center Customer Service Survey / OKC HB Primary Care Satisfaction Survey Other-Script / Survey	Modified
210095	Survey of Patient Satisfaction at Surgical Service Form	Modified
209895	HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey Form	Modified
209046	Rehabilitation Care Survey/HEC Vet Enrollment Survey/Project ARCH non-sub change Form	Modified
208635	National Patient Centered Community Care Survey Questions / Oklahoma City (OKC) VAMC Dental Patient Satisfaction Survey Form	Modified
208193	Outpatient Pharmacy Customer Satisfaction Survey Form	Modified
207373	MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey Form	Modified
206947	Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey Form	Modified
206838	Boston VAMC Ophthamology Satisfaction Survey / VISN 20 Telephone Call Center Satisfaction Survey Form	Modified
206725	Patient Satisfaction Surveys: Radiation Oncology/VISN 12 Telephone Care Service Form	Modified
206447	DeBakey Home Care Satisfaction Survey / CPEP Veterans Satisfaction Survey Form and Instruction	Modified
206171	Vet Apptmnt Apps Satisfaction Srvy/Hem-Oncology Telehealth Satisfaction Svy Other-Mobile application	Modified
205929	VHA Customer Value Online Survey / Customer Value Focus Group Other-Online Survey	Modified
205547	Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey Form	Modified
205012	PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey Form	Modified
203264	VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction Form	Modified
202594	Survey of Veterans Perceptions of an Enhanced VA Outpatient Prescription Label Form	Modified
202280	Community Living Center (CLC) Satisfaction Survey; Cardiac Cath Lab Satisfaction Survey; Psychiatric Patient Survey Form	Modified
201966	Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey Form	Modified
200925	Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey Form	Modified
200294	PACT Lab Caregiver and Patient Focus Groups; Point of Care (POC) Patient and Provider Focus Groups; Telehealth in the PADRECC: Veteran Focus Group; COMM Patient Survey; Office of Public Health Survey Other-guide/script	Modified
200161	VHA Generic Request: Notice Nurse Comment Card; Low Vision Clinic Patient Satisfaction Survey; Vendor Registration; Telephone Transformation Focus Group Form	Modified
199628	Project ARCH (Access received Closer to Home) Patient Satisfaction Survey Form and Instruction	Modified
199627	Telephone Survey on User Experience and Satisfaction with the Virtual Lifetime Electronic Record (VLER) Health Data Exchange Other-Interviewer Script	Unchanged
199626	Patient Satisfaction Questionnaire: Network Consolidated Laboratory (NCL) Phlebotomy Service Form	Modified
199625	Clinical Video Telehealth (CVT) Patient Satisfaction Survey Form	Modified
199589	Veterans Transportation Service (VTS) Veterans Satisfaction Questionnaire Form	Modified

ICR Details

OMB Control No: 2900-0770	ICR Reference No: 201403-2900-007
Status: Historical Active	Previous ICR Reference No: 201107-2900-001
Agency/Subagency: VA	Agency Tracking No: 2900-0770
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/21/2014
	Date Received in OIRA: 06/27/2014
Terms of Clearance: OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2017	06/30/2014	08/31/2014
Responses	200,000	0	200,000
Time Burden (Hours)	100,000	0	100,000
Cost Burden (Dollars)	0	0	0

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Abstract: The generic clearance will be used to collect qualitative feedback on VA's services or products delivery. VA will seek customer and stakeholder perceptions, experiences and expectations on its services or products delivery. The data collected will be used to improve delivery of products or services in areas where needed.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standard
  

Citations for New Statutory Requirements: EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 59	03/27/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 123	06/26/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 91

IC Title	Form No.	Form Name
Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey	VA Form 10-211002	Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey
Verification Cost of Compliance
Telebenefits Satisfaction Survey
Health Advocate Survey
Community Residential Care
MFH Veteran Survey
Supplier Perception Survey
Patient Satisfaction Questionnaire: Network Consolidated Laboratory (NCL) Phlebotomy Service	VA Form 10-0516	Patient Satisfaction Questionnaire: Laboratory P&LMS VA New England Healthcare System
Veterans Transportation Service (VTS) Veterans Satisfaction Questionnaire	VA Form 10-0517	Veterans Transportation Service (VTS) Questionnaire
Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey	VA Form 10-0531, VA Form 10-0542, VA Form 10-0540, VA Form 10-0538	Childcare Services Satisfaction Survey ,   Purchased Care Patient Satisfaction Survey ,   Teleretinal Patient Satisfaction Survey ,   Spinal Cord Home Care Survey
Survey of Veterans Perceptions of an Enhanced VA Outpatient Prescription Label	VA Form 10-0549	Rx Label Feedback
Boston VAMC Ophthamology Satisfaction Survey / VISN 20 Telephone Call Center Satisfaction Survey	VA Form 10-211001NR, VA Form 10-10059	Patient Satisfaction Survey_Boston VAMC_Dept. of Ophthamology ,   Telephone Customer Service Experience Satisfaction Survey
VA Office of Construction and Facilities Management (CFM) Supplier Satisfaction Survey Revision	VA Form 10163	CFM Supplier Satisfaction Survey
CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score	10-10168, 10-10169, 10-10170, 10-10171, 10-10172	PIM Patient Letter ,   PIM Patient INterview Guide ,   PIM Stakeholder Interview ,   VPS Survey Questions ,   Watson's Caritas Patient Survey
Health Research Multilevel Engagement, SORCC Patient Survey,	10-10147, 10-10145, 2900-0770, 10-10142	Womens Health Research Network ,   SOU-SORCC Patient Survey ,   State Veterans Home Patient Satisfaction ,   VHA OSI Primary Care Survey
VCP_VACC Provider Survey	10-1500210(WS), 10-1500209(WS)	VACC Provider Survey ,   VCP Provider Survey
Non-VA Behavioral Health Care
Veterans Experience Appointment Schedule Survey
Board of Veterans Appeals Hearing Experience Surveys
Veterans Affairs Acquisition 360 Survey
Feedback USA Button
Veterans Experience Appointment Schedule Survey (Rev)
Project ARCH (Access received Closer to Home) Patient Satisfaction Survey	VA Form 10-0522	Project ARCH (Access Received Closer to Home) Patient Satisfaction Survey
DeBakey Home Care Satisfaction Survey / CPEP Veterans Satisfaction Survey	VA Form 10-0476, VA Form 10-0480	Michael E. DeBakey Patient Satisfaction Survey ,   Compensation and Pension Examination Program (CPEP) Veterans Satisfaction Survey
Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey	10-10122, 10-10123, 10-10126, 10-10125	HME Vendor Performance Survey ,   MH Veteran Survey ,   Patient Satisfaction Survey ,   Prosthetics Customer Service Survey
2014 NVSBE Post-Engagement	2900-0770	2014 NVSBE Post-Engagement Survey
Primary Care Satisfaction and Effectiveness Survey
HRC Satisfaction Survey
VAR Mobile App Rev_8-2016
Extended Hours Program Evaluation, Maternity Care Coordination, Advanced Education Veteran Survey, State Veterans Home Administrator Survey, VOV Conjoint Survey	10-10132, 10-10131, 10-10128, 10-10136, 10-10129, 10-10144	Extended Hours Evaluation - Non-Users ,   Extended Hours Evaluation - Users ,   Maternity Care Coordination Survey ,   Advanced Education Veteran Survey ,   State Veterans Home Admin Survey ,   Voice of the Veteran (VOV) Satisfaction Survey Office of Strategic Integration (OSI) Conjoint Analysis
Veterans Experience Initiative	10-0516, 10-0476	NCL Patient Satisfaction Questionnaire ,   Michael E. DeBakey Home Care Program
MHICM Consumer Satisfaction Survey
MFH Caregiver Survey
PTSD Consultation Program
VE Feedback Tool: eComment Card
VA Pittsburgh Health Care System Emergency Department Survey
MHV Summative Test
NAC Customer Response Survey
Clinical Video Telehealth (CVT) Patient Satisfaction Survey	VA Form 10-0481a	Clinical Video Telehealth (CVT) Patient Satisfaction Survey
National Patient Centered Community Care Survey Questions / Oklahoma City (OKC) VAMC Dental Patient Satisfaction Survey	10-211009, 10-211008	Dental (Ambulatory) Patient Satisfaction Survey ,   National Patient Centered Community Care Veterans Survey Question
OSDBU Post-Event Evaluation	2900-0770	OSDBU Post-Event Evaluation
VAInfoApp	10-1500199(WS)	MySurvey
Veteran Experience and Satisfaction with the Department of Veterans Affairs Compensation and Pension Claims Examination Survey
VA Conjoint Survey - External Communication	10-1500188(WS)	VA External Communication Conjoint Questionnaire
PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey	VA Form 10-0496, VA Form 10-0495, VA Form 10-0497, VA Form 10-0496a	Understanding PTSD for Family Caregivers: Feedback Survey ,   VA Courtesy Standards - The Golden Rule Approach Veteran Feedback Form ,   PTSD Coach App Survey ,   Phone Apps Focus Group Demographic Questionnaire
VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction	VA Form 10-0551, VA Form 10-0553S, VA form 10-0552, VA form 10-0553, VA Form 10-0554	VCS Patriot Store and VCS Patriot Cafe Customer Satisfaction Survey ,   Patient Experience of Care Survey ,   Dental Service Customer Satisfaction Survey ,   Dental Satisfaction Survey (Spanish version) ,   Office of Mental Health Veteran Satisfaction Survey
Congressional Response Team Customer Satisfaction Survey
Rehabilitation and Audiology Customer Service Survey
CWT IT Stakeholders Satisfaction Survey
VA Pittsburgh Reseach Survey
Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care	10-0552, 10-0450, 10-0455, 10-0457	Veterans Choice Program Survey ,   Nationwide Dialysis Program Survey ,   VLER Program Survey ,   Patient Experience of Care Survey
MHV Website Redesign, National Family Caregiver Survey, MEC Notification Survey	10-10155, 10-10119, 10-10114	National Family Caregiver Participant Training Feedback Form ,   MEC Notification Survey ,   Caregiver Feedback Form
IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction Survey	10-10128, 10-10130, 10-10133, 10-10136, 10-10131, 10-10135	IOM VA Mental Health Services Evaluation ,   IOM VA Mental Health Services Evaluation ,   IOM VA Mental Health Services Evaluation ,   VISN 1 Patient Satisfaction Survey ,   Battlecreek Urgent Care Survey ,   Tobacco and Smoking Cessation Survey
MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey	VA Form 10-211004, VA Form 10-211003, VA Form 10-211005	MSCoE Patient Survey ,   PROJECT ARCH (Access Received Closer to Home) Non-Participating Veterans Survey ,   Patient Survey: Waiting Room Television Video Patient Education
Shared Decision Making
CWT IT Consumers Satisfaction Survey_1
Veterans Millennium Act Emergency Care Benefit Satisfaction Survey
VHA Women Veterans Call Center
Mental Health - SORCC
VHA Generic Request: Notice Nurse Comment Card; Low Vision Clinic Patient Satisfaction Survey; Vendor Registration; Telephone Transformation Focus Group	VA form 10-0519, VA Form 10-0528, VA Form 10-0527	PVAMC Low Vision Patient Satisfaction Survey ,   Notice Your Nurse ,   Vendor Application for Fair
Community Living Center (CLC) Satisfaction Survey; Cardiac Cath Lab Satisfaction Survey; Psychiatric Patient Survey	VA Form 10-0548, VA Form 10-0547, VA Form 10-0550	Community Living Center (CLC) Satisfaction Survey ,   Cardiac Cath Lab Customer Satisfaction Survey ,   Psychiatric Patient Satisfaction Survey
Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey	VA Form 10-0498, VA Form 10-0500, VA Form 10-0558, VA Form 10-0499, VA Form 10-0559	Food and Nutrition Satisfaction Survey ,   Fraud, Waste and Abuse Complaint Form ,   Epilepsy Centers of Excellence (ECoE) Patient Satisfaction Survey ,   Building Better Caregivers Satisfaction Survey ,   Sodium Dichromate Exposure Exam Feedback Survey
Awards and ROI-2013 NVSBC	2900-0770, 2900-0770	Awards and ROI - 2013 NVSBC ,   Awards and ROI-2013 NVSBC
Survey of Patient Satisfaction at Surgical Service	VA Form 10-211015, VA Form 10-211015SP	Survey of Patient Satisfaction at Surgical Service ,   Spanish version: Survey of Patient Satisfaction at Surgical Services
VISN 1 Call Center Customer Service Survey / OKC HB Primary Care Satisfaction Survey	VA Form 10-211014a	Oklahoma City VAMC Home Based Primary Care (HBPC) Program
Outpatient Pharmacy Customer Satisfaction Survey	VA Fform 10-211006NR	Outpatient Pharmacy Customer Satisfaction Survey
Patient Satisfaction Surveys: Radiation Oncology/VISN 12 Telephone Care Service	VA Form 10-10063, VA Form 10-10058	Patient Satisfaction Survey- Radiation Oncology ,   Telephone Care Services Patient Satisfaction Survey
Veteran Experience and Satisfaction with the Department of Veteran Affairs Compensation and Pension Claims Examination
VACT Primary Care Patient Satisfaction Questionnaire
Debt Management Center - Customer Service Experience
OPA Patient Satisfaction, Audiology Survey, National Rollout Survey, Telehealth Survey	10-0526, 10-10128, 10-10129, 10-10127	Caribean Harvey Survey ,   Audiology Hearing Aid Questionaire ,   Mental Health Survey ,   Telehealth Master Preceptor
Health Advocate Survey
Survey regarding effectiveness of the GI Bill Feedback System
Clinic Based Telehealth Satisfaction Survey	10-0481a	VA Telehealth Patient Survey
Admission Process Customer Satisfaction Survey - Roseburg VAMC
VISN 20 Cancer Care Survey, VA Research Currents	VA Form 10-10167, VA Form 10-10164	VISN 20 Cancer Care Survey ,   Customer Satisfaction Survey on VA Research Communication, VA Research Currents
2014 Post-9/11 GI Bill Communications Assessment
2014 NVSBE Events Satisfaction	2900-0770, 2900-0770, 2900-0770, 2900-0770, 2900-0770, 2900-0770	Business Requirement Sessions ,   CVE Booth Satisfaction ,   Exhibitor Satisfaction ,   Learning Sessions ,   NRT Satisfaction ,   Senior Leaders Roundtables
Vet Apptmnt Apps Satisfaction Srvy/Hem-Oncology Telehealth Satisfaction Svy
VHA Customer Value Online Survey / Customer Value Focus Group
Cooperative Studies Program	10-1500196(WS), 10-1500197(WS)	CSPCC Study Chairperson and NSC Survey ,   DMC Survey
VE Access Survey Questions
Mental Health - SORCC Satisfaction Survey
CWT TW Consumers Satisfaction Survey
Telephone Survey on User Experience and Satisfaction with the Virtual Lifetime Electronic Record (VLER) Health Data Exchange
Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey	VA Form 10-0515, VA Form 10-0520, VA Form 10-0541, VA Form 10-0545, VA Form 10-0546	Spinal Cord Injury Patient Survey ,   National Family Caregiver Participant Training Feedback Form ,   Survey of Veterans' Satisfaction with Income Verification ,   Non-VA Care Coordination Veteran Satisfaction Survey ,   Nuerology/Rehabilitation Inpatient Program Satisfaction Survey
Rehabilitation Care Survey/HEC Vet Enrollment Survey/Project ARCH non-sub change	VA Form 10-211004, VA Form 10-211010, VA Form 10-211013	Survey of Rehabilitation Care Survey ,   HEC Enrollment Survey ,   Project ARCH Non-Participant Survey
HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey	VA Form 10-211016, VA Form 10-211014, VA Form 10-211013, VA Form 10-211011	Home Based Primary Care Survey ,   Non-VA-Purchased Care Veteran Survey ,   Dental Insurance Program Survey ,   Tele-Dermatology Imaging Patient Satisfaction Survey
Voice of the Customer Questionnaire for Pharmacy Choice
Customer Satisfaction Survey for Claims Clinics Pilot Program
PACT Lab Caregiver and Patient Focus Groups; Point of Care (POC) Patient and Provider Focus Groups; Telehealth in the PADRECC: Veteran Focus Group; COMM Patient Survey; Office of Public Health Survey	VA Form 10-0526, Article and Volume Number of Newsletter	The Continuity of Medication Management Patient Survey ,   Office of Public Health Gulf War Newsletter Survey

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	200,000	200,000	0	0	0	0
Annual Time Burden (Hours)	100,000	100,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: New Collection.

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Annual Cost to Federal Government: $300,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/27/2014

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