Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0770 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 10-211002 Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey Form
VA Form 10-211002 Anticoagulation (warfarin/Coumadin) Patient Satisfaction Anticoagulation Satisfaction Survey_10-211002.pdf www.surveymonkey.com/s/VISN1_Anticoagulation Form
Anticoagulation Satisfaction Survey Request.docx Anticoagulation (warfarin/Coumadin)Satisfaction Survey Request IC Document
Justification for Questions 1 thru 4.docx Justification for questions 1 thru 4 IC Document

Information Collection (IC) Details

IC Title:	Anticoagulation (Warfarin/Coumadin) Patient Satisfaction Survey	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 10-211002	Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey	Anticoagulation Satisfaction Survey_10-211002.pdf	https://www.surveymonkey.com/s/VISN1_Anticoagulation	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,800	4,800
Annual IC Time Burden (Hours)	560	560
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Anticoagulation (warfarin/Coumadin)Satisfaction Survey Request	Anticoagulation Satisfaction Survey Request.docx	05/20/2013
Justification for questions 1 thru 4	Justification for Questions 1 thru 4.docx	05/20/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.