Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
2014 NVSBE Events Satisfaction New 16225 541 0 Form and Instruction 2900-0770 Business Requirement Sessions
Form and Instruction 2900-0770 CVE Booth Satisfaction
Form and Instruction 2900-0770 Exhibitor Satisfaction
Form and Instruction 2900-0770 Learning Sessions
Form and Instruction 2900-0770 NRT Satisfaction
Form and Instruction 2900-0770 Senior Leaders Roundtables
2014 NVSBE Post-Engagement New 3500 15 0 Form 2900-0770 2014 NVSBE Post-Engagement Survey
2014 Post-9/11 GI Bill Communications Assessment New 100 75 0 Other-Survey
Admission Process Customer Satisfaction Survey - Roseburg VAMC New 304 25 0 Other-Survey
Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey Modified 4800 560 0 Form VA Form 10-211002 Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey
Awards and ROI-2013 NVSBC New 1639 89 0 Form 2900-0770 Awards and ROI-2013 NVSBC
Form 2900-0770 Awards and ROI - 2013 NVSBC
Board of Veterans Appeals Hearing Experience Surveys New 8000 917 0 Other-Web Survey
Other-Phone Survey
Boston VAMC Ophthamology Satisfaction Survey / VISN 20 Telephone Call Center Satisfaction Survey Modified 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
CBO-Veterans Point of Service; PACT Intensive Management Evaluation; Watson Caritas Patient Score New 5350 467 0 Form and Instruction 10-10168 PIM Patient Letter
Form and Instruction 10-10169 PIM Patient INterview Guide
Form and Instruction 10-10170 PIM Stakeholder Interview
Form and Instruction 10-10171 VPS Survey Questions
Form and Instruction 10-10172 Watson's Caritas Patient Survey
CWT IT Consumers Satisfaction Survey_1 New 120 20 0 Other-Survey
CWT IT Stakeholders Satisfaction Survey New 10 2 0 Other-Survey
CWT TW Consumers Satisfaction Survey New 140 23 0 Other-Survey
Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey Modified 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
Clinic Based Telehealth Satisfaction Survey New 10000 2500 0 Form and Instruction 10-0481a VA Telehealth Patient Survey
Clinical Video Telehealth (CVT) Patient Satisfaction Survey Modified 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 Modified 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
Community Residential Care New 3200 267 0 Other-Survey
Congressional Response Team Customer Satisfaction Survey New 110 9 0 Other-Survey
Other-Survey Invitation
Other-Survey Reminder Letter
Cooperative Studies Program New 105 9 0 Form and Instruction 10-1500196(WS) DMC Survey
Form 10-1500197(WS) CSPCC Study Chairperson and NSC Survey
Customer Satisfaction Survey for Claims Clinics Pilot Program New 2000 333 0 Other-survey
DeBakey Home Care Satisfaction Survey / CPEP Veterans Satisfaction Survey Modified 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
Debt Management Center - Customer Service Experience New 18000 1800 0 Other-Survey
Extended Hours Program Evaluation, Maternity Care Coordination, Advanced Education Veteran Survey, State Veterans Home Administrator Survey, VOV Conjoint Survey New 1840 521 0 Form and Instruction 10-10129 Extended Hours Evaluation - Non-Users
Form and Instruction 10-10132 Extended Hours Evaluation - Users
Form and Instruction 10-10131 Maternity Care Coordination Survey
Form and Instruction 10-10128 Advanced Education Veteran Survey
Form and Instruction 10-10136 State Veterans Home Admin Survey
Form and Instruction 10-10144 Voice of the Veteran (VOV) Satisfaction Survey Office of Strategic Integration (OSI) Conjoint Analysis
Feedback USA Button New 1920 128 0 Other-Feed Back Button
Other-Feed Back Sample Questions
Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey Modified 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
HRC Satisfaction Survey New 35000 1750 0 Other-Telephone Script
Health Advocate Survey New 50 4 0 Other-Survey
Health Advocate Survey New 250 21 0 Other-Survey
Health Research Multilevel Engagement, SORCC Patient Survey, New 4477 1067 0 Form and Instruction 10-10142 Womens Health Research Network
Form and Instruction 10-10145 SOU-SORCC Patient Survey
Form and Instruction 2900-0770 State Veterans Home Patient Satisfaction
Form and Instruction 10-10147 VHA OSI Primary Care Survey
HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey Modified 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
IOM Study, NCL Patient Satisfaction Survey, Battlecreek Urgent Care Survey, Tobacco & Nicotine Use Survey, VISN 1 Patient Satisfaction Survey New 2990 897 0 Form and Instruction 10-10128 IOM VA Mental Health Services Evaluation
Form and Instruction 10-10130 IOM VA Mental Health Services Evaluation
Form and Instruction 10-10131 IOM VA Mental Health Services Evaluation
Form and Instruction 10-10133 VISN 1 Patient Satisfaction Survey
Form and Instruction 10-10135 Battlecreek Urgent Care Survey
Form and Instruction 10-10136 Tobacco and Smoking Cessation Survey
MFH Caregiver Survey New 700 58 0 Other-Survey
MFH Veteran Survey New 1000 83 0 Other-Survey
MHICM Consumer Satisfaction Survey New 60 10 0 Other-Survey
MHV Summative Test New 18 18 0 Other-Summative Test
MHV Website Redesign, National Family Caregiver Survey, MEC Notification Survey New 42029 5084 0 Form and Instruction 10-10155 MEC Notification Survey
Form and Instruction 10-10119 Caregiver Feedback Form
Form and Instruction 10-10114 National Family Caregiver Participant Training Feedback Form
MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey Modified 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
Mental Health - SORCC New 2500 104 0 Other-Survey
Mental Health - SORCC Satisfaction Survey New 2500 83 0 Instruction
Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey New 3160 1317 0 Form and Instruction 10-10122 HME Vendor Performance Survey
Form and Instruction 10-10123 MH Veteran Survey
Form and Instruction 10-10126 Patient Satisfaction Survey
Form and Instruction 10-10125 Prosthetics Customer Service Survey
NAC Customer Response Survey New 1000 83 0 Other-Web Based
National Patient Centered Community Care Survey Questions / Oklahoma City (OKC) VAMC Dental Patient Satisfaction Survey Modified 12400 1434 0 Form 10-211009 National Patient Centered Community Care Veterans Survey Question
Form 10-211008 Dental (Ambulatory) Patient Satisfaction Survey
Non-VA Behavioral Health Care New 150 25 0 Other-Survey
OPA Patient Satisfaction, Audiology Survey, National Rollout Survey, Telehealth Survey New 10366 0 0 Form and Instruction 10-0526 Caribean Harvey Survey
Form and Instruction 10-10128 Audiology Hearing Aid Questionaire
Form and Instruction 10-10129 Mental Health Survey
Form and Instruction 10-10127 Telehealth Master Preceptor
OSDBU Post-Event Evaluation New 10000 542 0 Form 2900-0770 OSDBU Post-Event Evaluation
Outpatient Pharmacy Customer Satisfaction Survey Modified 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 Modified 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 Consultation Program New 1200 200 0 Other-Feedback Survey
PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey Modified 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 Modified 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 Modified 560 66 0 Form VA Form 10-10063 Patient Satisfaction Survey- Radiation Oncology
Form VA Form 10-10058 Telephone Care Services Patient Satisfaction Survey
Primary Care Satisfaction and Effectiveness Survey New 1000 33 0 Other-Questionnaire
Project ARCH (Access received Closer to Home) Patient Satisfaction Survey Modified 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 Modified 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
Rehabilitation and Audiology Customer Service Survey New 240 60 0 Other-Telephone Script
Shared Decision Making New 150 25 0 Other-Veteran Telephone Script
Other-Caregiver Telephone Script
Other-Glossary
Other-Phone Interview Script
Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey Modified 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
Supplier Perception Survey New 12400 1033 0 Other-Web Survey
Survey of Patient Satisfaction at Surgical Service Modified 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 Modified 5600 373 0 Form VA Form 10-0549 Rx Label Feedback
Survey regarding effectiveness of the GI Bill Feedback System New 250 0 0 Other-Survey Instrument
Telebenefits Satisfaction Survey New 4000 667 0 Other-
Telephone Survey on User Experience and Satisfaction with the Virtual Lifetime Electronic Record (VLER) Health Data Exchange Unchanged 220 55 0 Other-Interviewer Script
Other-Interviewer Script
VA Conjoint Survey - External Communication New 800 200 0 Form and Instruction 10-1500188(WS) VA External Communication Conjoint Questionnaire
VA Office of Construction and Facilities Management (CFM) Supplier Satisfaction Survey Revision New 1000 183 0 Form and Instruction VA Form 10163 CFM Supplier Satisfaction Survey
VA Pittsburgh Health Care System Emergency Department Survey New 4650 155 0 Other-Survey
VA Pittsburgh Reseach Survey New 100 5 0 Other-Research Survey
VACT Primary Care Patient Satisfaction Questionnaire New 400 100 0 Other-Questionnaire
VAInfoApp New 30 15 0 Form and Instruction 10-1500199(WS) MySurvey
VAR Mobile App Rev_8-2016 New 25 38 0 Other-Study Plan
VCP_VACC Provider Survey New 4000 667 0 Form and Instruction 10-1500210(WS) VACC Provider Survey
Form and Instruction 10-1500209(WS) VCP Provider Survey
Instruction
Other-Reminder Letter
VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction Modified 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
VE Access Survey Questions New 50000 833 0 Other-Email
VE Feedback Tool: eComment Card New 135 11 0 Other-Web: eComment Card
VHA Customer Value Online Survey / Customer Value Focus Group Modified 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 Modified 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
VHA Women Veterans Call Center New 130000 8667 0 Other-Survey Script
VISN 1 Call Center Customer Service Survey / OKC HB Primary Care Satisfaction Survey Modified 4350 314 0 Other-Script / Survey
Form VA Form 10-211014a Oklahoma City VAMC Home Based Primary Care (HBPC) Program
VISN 20 Cancer Care Survey, VA Research Currents New 3204 260 0 Form and Instruction VA Form 10-10164 VISN 20 Cancer Care Survey
Form and Instruction VA Form 10-10167 Customer Satisfaction Survey on VA Research Communication, VA Research Currents
Verification Cost of Compliance New 150 15 0 Other-Survey
Vet Apptmnt Apps Satisfaction Srvy/Hem-Oncology Telehealth Satisfaction Svy Modified 430 36 0 Other-Mobile application
Other-Web-based
Instruction
Veteran Experience and Satisfaction with the Department of Veteran Affairs Compensation and Pension Claims Examination New 10000 833 0 Other-Exam survey screen shot of url
Other-Customer Satisfaction Survey
Veteran Experience and Satisfaction with the Department of Veterans Affairs Compensation and Pension Claims Examination Survey New 10000 1167 0 Other-Survey
Veterans Affairs Acquisition 360 Survey New 420 105 0 Other-Survey
Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care New 10045 1339 0 Form and Instruction 10-0450 Veterans Choice Program Survey
Form and Instruction 10-0455 Nationwide Dialysis Program Survey
Form and Instruction 10-0457 VLER Program Survey
Form and Instruction 10-0552 Patient Experience of Care Survey
Veterans Experience Appointment Schedule Survey New 100000 1667 0 Other-eSurvey
Other-Email Invite
Veterans Experience Appointment Schedule Survey (Rev) New 1800000 30000 0 Other-E-Survey
Other-Evite_email
Veterans Experience Initiative New 491126 8185 0 Form and Instruction 10-0516 NCL Patient Satisfaction Questionnaire
Form and Instruction 10-0476 Michael E. DeBakey Home Care Program
Veterans Millennium Act Emergency Care Benefit Satisfaction Survey New 2000 233 0 Other-Survey
Other-Survey Invitation
Other-Survey Reminder Letter
Veterans Transportation Service (VTS) Veterans Satisfaction Questionnaire Modified 13482 1281 0 Form VA Form 10-0517 Veterans Transportation Service (VTS) Questionnaire
Voice of the Customer Questionnaire for Pharmacy Choice New 100 8 0 Other-Telephone Survey
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 3112069 99859 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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