View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey
 
Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form VA Form 10-211014 Home Based Primary Care Survey LawtonCBOC HB Primary Care Survey_10-211014.pdf No   Paper Only
Form VA Form 10-211013 Non-VA-Purchased Care Veteran Survey VA Form 10-211013_Non-VA PC Survey_10-2013.pdf URL to be determined Yes Yes Fillable Fileable
Form VA Form 10-211011 Dental Insurance Program Survey VA Form 10-211011 Dental Insurance Survey 10-13.pdf URL to be determined Yes Yes Fillable Fileable
Form VA Form 10-211016 Tele-Dermatology Imaging Patient Satisfaction Survey Tele-Dermatology Satisfaction Survey 10-211016.pdf TeleForm software will be used: URL TBD Yes Yes Fillable Fileable

Health Health Care Services

 

14,320 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 14,320 0 0 0 0 14,320
Annual IC Time Burden (Hours) 1,388 0 0 0 0 1,388
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Home Based Primary Care Patient Satisfaction Generic Submission_Home Based Primary Care.docx 12/30/2013
HBPC Survey Letter OKC/Lawton HBPC Survey Letter OKC.doc 12/30/2013
NonVA Purchased Care Veteran Survey VA Generic_Request_PurchasedCare Veteran Survey (v5)11-13.docx 12/30/2013
Dental Insurance Survey Generic_Submission_Dental Insurance Survey.docx 12/30/2013
Teledermatology Imaging Patient Satisfaction Survey Generic Request TeleDermatology Survey 01-28-14 (v2).docx 01/29/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.