Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
2014 Post-9/11 GI Bill Communications Assessment New 100 33 0 Other-Survey
Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey New 4800 560 0 Form VA Form 10-211002
Boston VAMC Ophthamology Satisfaction Survey / VISN 20 Telephone Call Center Satisfaction Survey New 2300 275 0 Form VA Form 10-211001NR
Form VA Form 10-10059
Building Better Caregivers TM Alumni Community Satisfaction Survey New 500 50 0 Form and Instruction 10-10119
CFM Supplier Electronic Comment Card / CFM Supplier Satisfaction Survey New 2000 167 0 Form VA Form 10164
Form VA Form 10163
Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey New 30875 1883 0 Form VA Form 10-0531
Form VA Form 10-0538
Form VA Form 10-0540
Form VA Form 10-0542
Other-Moderator Script
Other-Participant screener script
Clinical Video Telehealth (CVT) Patient Satisfaction Survey New 2500 125 0 Form VA Form 10-0481a
Community Living Center (CLC) Satisfaction Survey; Cardiac Cath Lab Satisfaction Survey; Psychiatric Patient Survey New 875 64 0 Form VA Form 10-0548
Form VA Form 10-0547
Form VA Form 10-0550
Customer Satisfaction Survey on VA Research Communication (Newsletter: VA Research Currents) New 204 10 0 Other-Customer survey
DeBakey Home Care Satisfaction Survey / CPEP Veterans Satisfaction Survey New 1714 170 0 Form and Instruction VA Form 10-0476
Form VA Form 10-0480
Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey New 129980 4941 0 Form VA Form 10-0498
Form VA Form 10-0500
Form VA Form 10-0558
Form and Instruction VA Form 10-0499
Form VA Form 10-0559
Generic Clearance for the Collection of Qualitative Feedback on VA Service and Delivery (NCA, VBA, VHA) Removed 0 0 0
HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey New 14320 1388 0 Form VA Form 10-211014
Form VA Form 10-211013
Form VA Form 10-211011
Form VA Form 10-211016
MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey New 7515 1866 0 Form VA Form 10-211003
Form VA Form 10-211004
Form VA Form 10-211005
National Patient Centered Community Care Survey Questions / Oklahoma City (OKC) VAMC Dental Patient Satisfaction Survey New 12400 1434 0 Form 10-211009
Form 10-211008
Outpatient Pharmacy Customer Satisfaction Survey New 50 4 0 Form VA Fform 10-211006NR
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 New 11356 1165 0 Other-guide/script
Other-guide/script
Other-Script
Other-Script
Other-guide/transcription
Form VA Form 10-0526
Form Article and Volume Number of Newsletter
PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey New 4420 1353 0 Form VA Form 10-0495
Other-Telephone Script
Instruction
Form VA Form 10-0497
Form VA Form 10-0496
Other-Focus Group Guide and Script
Other-Notification Letter
Form VA Form 10-0496a
Patient Satisfaction Questionnaire: Network Consolidated Laboratory (NCL) Phlebotomy Service New 1600 80 0 Form VA Form 10-0516
Patient Satisfaction Surveys: Radiation Oncology/VISN 12 Telephone Care Service New 560 66 0 Form VA Form 10-10063
Form VA Form 10-10058
Project ARCH (Access received Closer to Home) Patient Satisfaction Survey New 7200 1440 0 Form and Instruction VA Form 10-0522
Rehabilitation Care Survey/HEC Vet Enrollment Survey/Project ARCH non-sub change New 1328 271 0 Form VA Form 10-211010
Form VA Form 10-211013
Form VA Form 10-211004
Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey New 12920 1335 0 Form VA Form 10-0515
Form VA Form 10-0520
Form VA Form 10-0541
Form VA Form 10-0545
Form VA Form 10-0546
Other-Survey Cover Letter
Other-Survey Cover Letter
Survey of Patient Satisfaction at Surgical Service New 1825 608 0 Form VA Form 10-211015
Form VA Form 10-211015SP
Survey of Veterans Perceptions of an Enhanced VA Outpatient Prescription Label New 5600 373 0 Form VA Form 10-0549
Telephone Survey on User Experience and Satisfaction with the Virtual Lifetime Electronic Record (VLER) Health Data Exchange New 220 55 0 Other-Interviewer Script
Other-Interviewer Script
VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction New 11765 2632 0 Form VA Form 10-0551
Other-Training Script
Form VA form 10-0552
Form VA form 10-0553
Form VA Form 10-0553S
Form VA Form 10-0554
Other-Information Script
VHA Customer Value Online Survey / Customer Value Focus Group New 860 423 0 Other-Online Survey
Instruction
Instruction
VHA Generic Request: Notice Nurse Comment Card; Low Vision Clinic Patient Satisfaction Survey; Vendor Registration; Telephone Transformation Focus Group New 586 126 0 Form VA Form 10-0527
Form VA form 10-0519
Form VA Form 10-0528
Other-Script
VISN 1 Call Center Customer Service Survey / OKC HB Primary Care Satisfaction Survey New 4350 314 0 Other-Script / Survey
Form VA Form 10-211014a
Vet Apptmnt Apps Satisfaction Srvy/Hem-Oncology Telehealth Satisfaction Svy New 430 36 0 Other-Mobile application
Other-Web-based
Instruction
Veterans Transportation Service (VTS) Veterans Satisfaction Questionnaire New 13482 1281 0 Form VA Form 10-0517
Veterans Transportation Service Questionnaire New 2000 33 0 Other-Additional questions to previously approved questionnaire
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 290635 24561 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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