Form 10-10139 Evaluating Individual and Patient-Selected Family/Friend

Evaluating Individual and Patient-Selected
Family/Friend/or Reciprocal Peer Notification
to Improve Statin Medication Adherence
among Patients with Coronary Artery Disease
VA Form 10-10139
Arm 1
OMB No. 2900-XXXX
Estimated Burden: 35 Minutes
Expiration Date: XX/XX/20XX

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the
Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time
expended by all individuals who complete this survey will average 35 minutes. This includes the time it will take
to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used
to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this
telephone/mail survey will lead to improve engagement with patients significantly easier and more immediate
improvements using newer technology to improve medication adherence. Participation in this survey is
voluntary and failure to respond will have no impact on benefits to which you may be entitled.

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