View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View Generic ICR - OIRA Conclusion
OMB Control No:
2900-0770
ICR Reference No:
201107-2900-001
Status:
Historical Active
Previous ICR Reference No:
201102-2900-008
Agency/Subagency:
VA
Agency Tracking No:
2900-0770
Title:
Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
07/08/2011
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/08/2011
Terms of Clearance:
OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
06/30/2014
06/30/2014
06/30/2014
Responses
200,000
0
200,000
Time Burden (Hours)
100,000
0
100,000
Cost Burden (Dollars)
0
0
0
Abstract:
The generic clearance will be used to collect qualitative feedback on VA's services or products delivery. VA will seek customer and stakeholder perceptions, experiences and expectations on its services or products delivery. The data collected will be used to improve delivery of products or services in areas where needed.
Authorizing Statute(s):
EO: EO 12862 Name/Subject of EO: Setting Customer Service Standard
Citations for New Statutory Requirements:
EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
75 FR 80542
12/22/2010
30-day Notice:
Federal Register Citation:
Citation Date:
76 FR 13019
03/09/2011
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
32
IC Title
Form No.
Form Name
2014 Post-9/11 GI Bill Communications Assessment
Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey
VA Form 10-211002
Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey
Boston VAMC Ophthamology Satisfaction Survey / VISN 20 Telephone Call Center Satisfaction Survey
VA Form 10-211001NR, VA Form 10-10059
Patient Satisfaction Survey_Boston VAMC_Dept. of Ophthamology
,
Telephone Customer Service Experience Satisfaction Survey
Building Better Caregivers TM Alumni Community Satisfaction Survey
10-10119
Building Better Caregivers TM Alumni Community Satisfaction Survey
CFM Supplier Electronic Comment Card / CFM Supplier Satisfaction Survey
VA Form 10163, VA Form 10164
CFM Supplier Electronic Comment Card
,
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
VA Form 10-0531, VA Form 10-0542, VA Form 10-0540, VA Form 10-0538
Childcare Services Satisfaction Survey
,
Purchased Care Patient Satisfaction Survey
,
Teleretinal Patient Satisfaction Survey
,
Spinal Cord Home Care Survey
Clinical Video Telehealth (CVT) Patient Satisfaction Survey
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
VA Form 10-0548, VA Form 10-0547, VA Form 10-0550
Community Living Center (CLC) Satisfaction Survey
,
Cardiac Cath Lab Customer Satisfaction Survey
,
Psychiatric Patient Satisfaction Survey
Customer Satisfaction Survey on VA Research Communication (Newsletter: VA Research Currents)
DeBakey Home Care Satisfaction Survey / CPEP Veterans Satisfaction Survey
VA Form 10-0476, VA Form 10-0480
Michael E. DeBakey Patient Satisfaction Survey
,
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
VA Form 10-0498, VA Form 10-0500, VA Form 10-0558, VA Form 10-0499, VA Form 10-0559
Food and Nutrition Satisfaction Survey
,
Fraud, Waste and Abuse Complaint Form
,
Epilepsy Centers of Excellence (ECoE) Patient Satisfaction Survey
,
Building Better Caregivers Satisfaction Survey
,
Sodium Dichromate Exposure Exam Feedback Survey
Generic Clearance for the Collection of Qualitative Feedback on VA Service and Delivery (NCA, VBA, VHA)
HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey
VA Form 10-211016, VA Form 10-211014, VA Form 10-211013, VA Form 10-211011
Home Based Primary Care Survey
,
Non-VA-Purchased Care Veteran Survey
,
Dental Insurance Program Survey
,
Tele-Dermatology Imaging Patient Satisfaction Survey
MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey
VA Form 10-211004, VA Form 10-211003, VA Form 10-211005
MSCoE Patient Survey
,
PROJECT ARCH (Access Received Closer to Home) Non-Participating Veterans Survey
,
Patient Survey: Waiting Room Television Video Patient Education
National Patient Centered Community Care Survey Questions / Oklahoma City (OKC) VAMC Dental Patient Satisfaction Survey
10-211009, 10-211008
National Patient Centered Community Care Veterans Survey Question
,
Dental (Ambulatory) Patient Satisfaction Survey
Outpatient Pharmacy Customer Satisfaction Survey
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
VA Form 10-0526, Article and Volume Number of Newsletter
The Continuity of Medication Management Patient Survey
,
Office of Public Health Gulf War Newsletter Survey
PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey
VA Form 10-0496, VA Form 10-0495, VA Form 10-0497, VA Form 10-0496a
Understanding PTSD for Family Caregivers: Feedback Survey
,
VA Courtesy Standards - The Golden Rule Approach Veteran Feedback Form
,
PTSD Coach App Survey
,
Phone Apps Focus Group Demographic Questionnaire
Patient Satisfaction Questionnaire: Network Consolidated Laboratory (NCL) Phlebotomy Service
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
VA Form 10-10063, VA Form 10-10058
Patient Satisfaction Survey- Radiation Oncology
,
Telephone Care Services Patient Satisfaction Survey
Project ARCH (Access received Closer to Home) Patient Satisfaction Survey
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
VA Form 10-211004, VA Form 10-211010, VA Form 10-211013
Survey of Rehabilitation Care Survey
,
HEC Enrollment Survey
,
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
VA Form 10-0515, VA Form 10-0520, VA Form 10-0541, VA Form 10-0545, VA Form 10-0546
Spinal Cord Injury Patient Survey
,
National Family Caregiver Participant Training Feedback Form
,
Survey of Veterans' Satisfaction with Income Verification
,
Non-VA Care Coordination Veteran Satisfaction Survey
,
Nuerology/Rehabilitation Inpatient Program Satisfaction Survey
Survey of Patient Satisfaction at Surgical Service
VA Form 10-211015, VA Form 10-211015SP
Survey of Patient Satisfaction at Surgical Service
,
Spanish version: Survey of Patient Satisfaction at Surgical Services
Survey of Veterans Perceptions of an Enhanced VA Outpatient Prescription Label
VA Form 10-0549
Rx Label Feedback
Telephone Survey on User Experience and Satisfaction with the Virtual Lifetime Electronic Record (VLER) Health Data Exchange
VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction
VA Form 10-0551, VA Form 10-0553S, VA form 10-0552, VA form 10-0553, VA Form 10-0554
VCS Patriot Store and VCS Patriot Cafe Customer Satisfaction Survey
,
Patient Experience of Care Survey
,
Dental Service Customer Satisfaction Survey
,
Dental Satisfaction Survey (Spanish version)
,
Office of Mental Health Veteran Satisfaction Survey
VHA Customer Value Online Survey / Customer Value Focus Group
VHA Generic Request: Notice Nurse Comment Card; Low Vision Clinic Patient Satisfaction Survey; Vendor Registration; Telephone Transformation Focus Group
VA form 10-0519, VA Form 10-0528, VA Form 10-0527
PVAMC Low Vision Patient Satisfaction Survey
,
Notice Your Nurse
,
Vendor Application for Fair
VISN 1 Call Center Customer Service Survey / OKC HB Primary Care Satisfaction Survey
VA Form 10-211014a
Oklahoma City VAMC Home Based Primary Care (HBPC) Program
Vet Apptmnt Apps Satisfaction Srvy/Hem-Oncology Telehealth Satisfaction Svy
Veterans Transportation Service (VTS) Veterans Satisfaction Questionnaire
VA Form 10-0517
Veterans Transportation Service (VTS) Questionnaire
Veterans Transportation Service Questionnaire
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
200,000
200,000
0
0
0
0
Annual Time Burden (Hours)
100,000
100,000
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
New Collection.
Annual Cost to Federal Government:
$300,000
Does this IC contain surveys, censuses, or employ statistical methods?
Yes
Part B of Supporting Statement
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Denise McLamb 202-565-8374 denise.mclamb@mail.va.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
07/08/2011
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