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 Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey
Boston VAMC Ophthamology Satisfaction Survey / VISN 20 Telephone Call Center Satisfaction Survey New 2300 275 0 Form VA Form 10-211001NR Patient Satisfaction Survey_Boston VAMC_Dept. of Ophthamology
Form VA Form 10-10059 Telephone Customer Service Experience Satisfaction Survey
Building Better Caregivers TM Alumni Community Satisfaction Survey New 500 50 0 Form and Instruction 10-10119 Building Better Caregivers TM Alumni Community Satisfaction Survey
CFM Supplier Electronic Comment Card / CFM Supplier Satisfaction Survey New 2000 167 0 Form VA Form 10164 CFM Supplier Electronic Comment Card
Form VA Form 10163 CFM Supplier Satisfaction Survey
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 Childcare Services Satisfaction Survey
Form VA Form 10-0538 Purchased Care Patient Satisfaction Survey
Form VA Form 10-0540 Teleretinal Patient Satisfaction Survey
Form VA Form 10-0542 Spinal Cord Home Care Survey
Other-Moderator Script
Other-Participant screener script
Clinical Video Telehealth (CVT) Patient Satisfaction Survey New 2500 125 0 Form VA Form 10-0481a Clinical Video Telehealth (CVT) Patient Satisfaction Survey
Community Living Center (CLC) Satisfaction Survey; Cardiac Cath Lab Satisfaction Survey; Psychiatric Patient Survey New 875 64 0 Form VA Form 10-0548 Community Living Center (CLC) Satisfaction Survey
Form VA Form 10-0547 Cardiac Cath Lab Customer Satisfaction Survey
Form VA Form 10-0550 Psychiatric Patient Satisfaction Survey
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 Michael E. DeBakey Patient Satisfaction Survey
Form VA Form 10-0480 Compensation and Pension Examination Program (CPEP) Veterans Satisfaction Survey
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 Food and Nutrition Satisfaction Survey
Form VA Form 10-0500 Fraud, Waste and Abuse Complaint Form
Form VA Form 10-0558 Epilepsy Centers of Excellence (ECoE) Patient Satisfaction Survey
Form and Instruction VA Form 10-0499 Building Better Caregivers Satisfaction Survey
Form VA Form 10-0559 Sodium Dichromate Exposure Exam Feedback Survey
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 Home Based Primary Care Survey
Form VA Form 10-211013 Non-VA-Purchased Care Veteran Survey
Form VA Form 10-211011 Dental Insurance Program Survey
Form VA Form 10-211016 Tele-Dermatology Imaging Patient Satisfaction Survey
MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey New 7515 1866 0 Form VA Form 10-211003 MSCoE Patient Survey
Form VA Form 10-211004 PROJECT ARCH (Access Received Closer to Home) Non-Participating Veterans Survey
Form VA Form 10-211005 Patient Survey: Waiting Room Television Video Patient Education
National Patient Centered Community Care Survey Questions / Oklahoma City (OKC) VAMC Dental Patient Satisfaction Survey New 12400 1434 0 Form 10-211009 National Patient Centered Community Care Veterans Survey Question
Form 10-211008 Dental (Ambulatory) Patient Satisfaction Survey
Outpatient Pharmacy Customer Satisfaction Survey New 50 4 0 Form VA Fform 10-211006NR Outpatient Pharmacy Customer Satisfaction Survey
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 The Continuity of Medication Management Patient Survey
Form Article and Volume Number of Newsletter Office of Public Health Gulf War Newsletter Survey
PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey New 4420 1353 0 Form VA Form 10-0495 Understanding PTSD for Family Caregivers: Feedback Survey
Other-Telephone Script
Instruction
Form VA Form 10-0497 VA Courtesy Standards - The Golden Rule Approach Veteran Feedback Form
Form VA Form 10-0496 PTSD Coach App Survey
Other-Focus Group Guide and Script
Other-Notification Letter
Form VA Form 10-0496a Phone Apps Focus Group Demographic Questionnaire
Patient Satisfaction Questionnaire: Network Consolidated Laboratory (NCL) Phlebotomy Service New 1600 80 0 Form VA Form 10-0516 Patient Satisfaction Questionnaire: Laboratory P&LMS VA New England Healthcare System
Patient Satisfaction Surveys: Radiation Oncology/VISN 12 Telephone Care Service New 560 66 0 Form VA Form 10-10063 Patient Satisfaction Survey- Radiation Oncology
Form VA Form 10-10058 Telephone Care Services Patient Satisfaction Survey
Project ARCH (Access received Closer to Home) Patient Satisfaction Survey New 7200 1440 0 Form and Instruction VA Form 10-0522 Project ARCH (Access Received Closer to Home) Patient Satisfaction Survey
Rehabilitation Care Survey/HEC Vet Enrollment Survey/Project ARCH non-sub change New 1328 271 0 Form VA Form 10-211010 Survey of Rehabilitation Care Survey
Form VA Form 10-211013 HEC Enrollment Survey
Form VA Form 10-211004 Project ARCH Non-Participant Survey
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 Spinal Cord Injury Patient Survey
Form VA Form 10-0520 National Family Caregiver Participant Training Feedback Form
Form VA Form 10-0541 Survey of Veterans' Satisfaction with Income Verification
Form VA Form 10-0545 Non-VA Care Coordination Veteran Satisfaction Survey
Form VA Form 10-0546 Nuerology/Rehabilitation Inpatient Program Satisfaction Survey
Other-Survey Cover Letter
Other-Survey Cover Letter
Survey of Patient Satisfaction at Surgical Service New 1825 608 0 Form VA Form 10-211015 Survey of Patient Satisfaction at Surgical Service
Form VA Form 10-211015SP Spanish version: Survey of Patient Satisfaction at Surgical Services
Survey of Veterans Perceptions of an Enhanced VA Outpatient Prescription Label New 5600 373 0 Form VA Form 10-0549 Rx Label Feedback
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 VCS Patriot Store and VCS Patriot Cafe Customer Satisfaction Survey
Other-Training Script
Form VA form 10-0552 Patient Experience of Care Survey
Form VA form 10-0553 Dental Service Customer Satisfaction Survey
Form VA Form 10-0553S Dental Satisfaction Survey (Spanish version)
Form VA Form 10-0554 Office of Mental Health Veteran Satisfaction Survey
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 PVAMC Low Vision Patient Satisfaction Survey
Form VA form 10-0519 Notice Your Nurse
Form VA Form 10-0528 Vendor Application for Fair
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 Oklahoma City VAMC Home Based Primary Care (HBPC) Program
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 (VTS) Questionnaire
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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