Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)

Forms and Documents

Document Name	Status
Form VA Form 10164 CFM Supplier Electronic Comment Card / CFM Supplier Satisfaction Survey Form	New
Form 10-10119 Building Better Caregivers TM Alumni Community Satisfaction Survey Form and Instruction	New
Form VA Form 10-211015 Survey of Patient Satisfaction at Surgical Service Form	New
Form VA Form 10-211014 HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey Form	New
Form VA Form 10-211010 Rehabilitation Care Survey/HEC Vet Enrollment Survey/Project ARCH non-sub change Form	New
Form 10-211009 National Patient Centered Community Care Survey Questions / Oklahoma City (OKC) VAMC Dental Patient Satisfaction Survey Form	New
Form VA Fform 10-211006 Outpatient Pharmacy Customer Satisfaction Survey Form	New
Form VA Form 10-211003 MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey Form	New
Form VA Form 10-211002 Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey Form	New
Form VA Form 10-211001N Boston VAMC Ophthamology Satisfaction Survey / VISN 20 Telephone Call Center Satisfaction Survey Form	New
Form VA Form 10-10063 Patient Satisfaction Surveys: Radiation Oncology/VISN 12 Telephone Care Service Form	New
Form VA Form 10-0476 DeBakey Home Care Satisfaction Survey / CPEP Veterans Satisfaction Survey Form and Instruction	New
Form VA Form 10-0498 Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey Form	New
Form VA Form 10-0551 VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction Form	New
Form VA Form 10-0549 Survey of Veterans Perceptions of an Enhanced VA Outpatient Prescription Label Form	New
Form VA Form 10-0548 Community Living Center (CLC) Satisfaction Survey; Cardiac Cath Lab Satisfaction Survey; Psychiatric Patient Survey Form	New
Form VA Form 10-0515 Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey Form	New
Form VA Form 10-0531 Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey Form	New
Form VA Form 10-0527 VHA Generic Request: Notice Nurse Comment Card; Low Vision Clinic Patient Satisfaction Survey; Vendor Registration; Telephone Transformation Focus Group Form	New
Form VA Form 10-0522 Project ARCH (Access received Closer to Home) Patient Satisfaction Survey Form and Instruction	New
Form VA Form 10-0516 Patient Satisfaction Questionnaire: Network Consolidated Laboratory (NCL) Phlebotomy Service Form	New
Form VA Form 10-0481a Clinical Video Telehealth (CVT) Patient Satisfaction Survey Form	New
Form VA Form 10-0517 Veterans Transportation Service (VTS) Veterans Satisfaction Questionnaire Form	New
Correction to burden hours for 2900-0770.docx Justification for No Material/Nonsubstantive Change	2011-07-08
Generic Clearance Submission Template (2).doc Supplementary Document	2011-06-01
Qualitative Feedback Justification B.docx Supporting Statement B	2011-02-18
(NCA VBA VHA)-Qualitative_Feedback_Justification A.doc Supporting Statement A	2011-05-31

IC Document Collections

IC ID	Document Title	Status
211581	Customer Satisfaction Survey on VA Research Communication (Newsletter: VA Research Currents) Other-Customer survey	New
211245	CFM Supplier Electronic Comment Card / CFM Supplier Satisfaction Survey Form	New
211244	Building Better Caregivers TM Alumni Community Satisfaction Survey Form and Instruction	New
211143	2014 Post-9/11 GI Bill Communications Assessment Other-Survey	New
210632	Veterans Transportation Service Questionnaire Other-Additional questions to previously approved questionnaire	New
210436	VISN 1 Call Center Customer Service Survey / OKC HB Primary Care Satisfaction Survey Other-Script / Survey	New
210095	Survey of Patient Satisfaction at Surgical Service Form	New
209895	HomeBased PrimaryCare Survey/Non-VA Purchased Care Survey/Vet Dental Insurance Survey/Teledermatology Imaging Patient Satisfaction Survey Form	New
209046	Rehabilitation Care Survey/HEC Vet Enrollment Survey/Project ARCH non-sub change Form	New
208635	National Patient Centered Community Care Survey Questions / Oklahoma City (OKC) VAMC Dental Patient Satisfaction Survey Form	New
208193	Outpatient Pharmacy Customer Satisfaction Survey Form	New
207373	MSCoE Patient Survey/Project ARCH Non-Participant Survey/Wait Rm Television Edu Survey Form	New
206947	Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey Form	New
206838	Boston VAMC Ophthamology Satisfaction Survey / VISN 20 Telephone Call Center Satisfaction Survey Form	New
206725	Patient Satisfaction Surveys: Radiation Oncology/VISN 12 Telephone Care Service Form	New
206447	DeBakey Home Care Satisfaction Survey / CPEP Veterans Satisfaction Survey Form and Instruction	New
206171	Vet Apptmnt Apps Satisfaction Srvy/Hem-Oncology Telehealth Satisfaction Svy Other-Mobile application	New
205929	VHA Customer Value Online Survey / Customer Value Focus Group Other-Online Survey	New
205547	Food and Nutrition Survey/Fraud,Waste,Abuse Complaint/Epilepsy Satisf-Survey/Building Better Caregivers Survey/Sodium Dichromate Feedback Survey Form	New
205012	PTSD Family Caregiver Feedback/ARCH Focus Group/VA Courtesy Standards/PTSD Coach (Phone) Apps Survey Other-Focus Group Guide and Script	New
203264	VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction Form	New
202594	Survey of Veterans Perceptions of an Enhanced VA Outpatient Prescription Label Form	New
202280	Community Living Center (CLC) Satisfaction Survey; Cardiac Cath Lab Satisfaction Survey; Psychiatric Patient Survey Form	New
201966	Spinal Cord Patient Survey; Caregiver Training Participant Feedback; Income Verification Survey; Non-VA Care Vet Survey; Neuro-Rehab Satisfaction Survey Form	New
200925	Childcare Service Satisfaction Survey; Purchased Care Online Survey; VHA ORD Focus Group Request; Teleretinal Patient Satisfaction Survey; Spinal Cord Home Care Satisfaction Survey Form	New
200294	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 Other-guide/script	New
200161	VHA Generic Request: Notice Nurse Comment Card; Low Vision Clinic Patient Satisfaction Survey; Vendor Registration; Telephone Transformation Focus Group Form	New
199628	Project ARCH (Access received Closer to Home) Patient Satisfaction Survey Form and Instruction	New
199627	Telephone Survey on User Experience and Satisfaction with the Virtual Lifetime Electronic Record (VLER) Health Data Exchange Other-Interviewer Script	New
199626	Patient Satisfaction Questionnaire: Network Consolidated Laboratory (NCL) Phlebotomy Service Form	New
199625	Clinical Video Telehealth (CVT) Patient Satisfaction Survey Form	New
199589	Veterans Transportation Service (VTS) Veterans Satisfaction Questionnaire Form	New
196310	Generic Clearance for the Collection of Qualitative Feedback on VA Service and Delivery (NCA, VBA, VHA)	Removed

ICR Details

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
	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

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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.

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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

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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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

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Number of Information Collection (IC) in this ICR: 32

IC Title	Form No.	Form Name
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
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
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
Customer Satisfaction Survey on VA Research Communication (Newsletter: VA Research Currents)
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
Clinical Video Telehealth (CVT) Patient Satisfaction Survey	VA Form 10-0481a	Clinical Video Telehealth (CVT) Patient 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
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
Outpatient Pharmacy Customer Satisfaction Survey	VA Fform 10-211006NR	Outpatient Pharmacy Customer Satisfaction Survey
Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey	VA Form 10-211002	Anticoagulation (warfarin/Coumadin) 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
Vet Apptmnt Apps Satisfaction Srvy/Hem-Oncology Telehealth Satisfaction Svy
2014 Post-9/11 GI Bill Communications Assessment
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
Telephone Survey on User Experience and Satisfaction with the Virtual Lifetime Electronic Record (VLER) Health Data Exchange
Veterans Transportation Service (VTS) Veterans Satisfaction Questionnaire	VA Form 10-0517	Veterans Transportation Service (VTS) Questionnaire
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
CFM Supplier Electronic Comment Card / CFM Supplier Satisfaction Survey	VA Form 10163, VA Form 10164	CFM Supplier Electronic Comment Card ,   CFM Supplier Satisfaction Survey
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
Patient Satisfaction Questionnaire: Network Consolidated Laboratory (NCL) Phlebotomy Service	VA Form 10-0516	Patient Satisfaction Questionnaire: Laboratory P&LMS VA New England Healthcare System
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
Building Better Caregivers TM Alumni Community Satisfaction Survey	10-10119	Building Better Caregivers TM Alumni Community Satisfaction Survey
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
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
VHA Customer Value Online Survey / Customer Value Focus Group
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
Survey of Veterans Perceptions of an Enhanced VA Outpatient Prescription Label	VA Form 10-0549	Rx Label Feedback
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
Generic Clearance for the Collection of Qualitative Feedback on VA Service and Delivery (NCA, VBA, VHA)
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
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
Veterans Transportation Service Questionnaire

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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.

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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

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Common Form ICR:  No

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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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