Prior OMB Notice of Approval for CFM Survey

NOTICE OF OFFICE OF MANAGEMENT AND BUDGET ACTION
Date

04/17/2014

Department of Veterans Affairs

FOR CERTIFYING OFFICIAL:

Roger Baker

FOR CLEARANCE OFFICER:

Crystal Rennie

In accordance with the Paperwork Reduction Act, OMB has taken action on your request received
04/14/2014
ACTION REQUESTED:

Generic IC

TYPE OF REVIEW REQUESTED:
ICR REFERENCE NUMBER:

201107-2900-001

AGENCY ICR TRACKING NUMBER:

2900-0770

TITLE:

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA,
VBA, VHA)
LIST OF INFORMATION COLLECTIONS: See next page
OMB ACTION: Approved without change
OMB CONTROL NUMBER:

2900-0770

The agency is required to display the OMB Control Number and inform respondents of its legal significance in
accordance with 5 CFR 1320.5(b).
EXPIRATION DATE:

DISCONTINUE DATE:

BURDEN:

RESPONSES

HOURS

COSTS

Previous

200,000

100,000

0

New

200,000

100,000

0

Change due to New Statute

0

0

0

Change due to Agency Discretion

0

0

0

Change due to Agency Adjustment

0

0

0

Change due to PRA Violation

0

0

0

Difference

TERMS OF CLEARANCE:

Terms of the Generic ICR remain in effect.

OMB Authorizing Official:

Dominic J. Mancini
Acting Deputy Administrator,
Office Of Information And Regulatory Affairs

IC Title

Form No.

List of ICs
Form Name

CFR Citation

Veterans Transportation VA Form 10-0517
Veterans Transportation 5 CFR 1320.8(d)
Service (VTS) Veterans
Service (VTS)
Satisfaction
Questionnaire
Questionnaire
Clinical Video
VA Form 10-0481a
Clinical Video Telehealth 5 CFR 1320.8(d)
Telehealth (CVT)
(CVT) Patient Satisfaction
Patient Satisfaction
Survey
Survey
Patient Satisfaction
VA Form 10-0516
Patient Satisfaction
5 CFR 1320.8(d)
Questionnaire: Network
Questionnaire: Laboratory
Consolidated
P&LMS VA New England
Laboratory (NCL)
Healthcare System
Phlebotomy Service
Telephone Survey on
5 CFR 1320.8(d)
User Experience and
Satisfaction with the
Virtual Lifetime
Electronic Record
(VLER) Health Data
Exchange
Project ARCH (Access VA Form 10-0522
Project ARCH (Access
5 CFR 1320.8(d)
received Closer to
Received Closer to Home)
Home) Patient
Patient Satisfaction
Satisfaction Survey
Survey
VHA Generic Request: VA Form 10-0527, VA PVAMC Low Vision
Notice Nurse Comment Form 10-0528, VA form Patient Satisfaction
Card; Low Vision Clinic 10-0519
Survey, Vendor
Patient Satisfaction
Application for Fair, Notice
Survey; Vendor
Your Nurse
Registration; Telephone
Transformation Focus
Group
PACT Lab Caregiver
Article and Volume
and Patient Focus
Number of Newsletter,
Groups; Point of Care VA Form 10-0526
(POC) Patient and
Provider Focus Groups;
Telehealth in the
PADRECC: Veteran
Focus Group; COMM
Patient Survey; Office of
Public Health Survey
Childcare Service
VA Form 10-0538, VA Purchased Care Patient
Satisfaction Survey;
Form 10-0540, VA Form Satisfaction Survey,
Purchased Care Online 10-0542, VA Form 10- Teleretinal Patient
Survey; VHA ORD
0531
Satisfaction Survey,
Focus Group Request;
Spinal Cord Home Care
Teleretinal Patient
Survey, Childcare
Satisfaction Survey;
Services Satisfaction
Spinal Cord Home Care
Survey
Satisfaction Survey
Spinal Cord Patient
VA Form 10-0515, VA Spinal Cord Injury Patient 5 CFR 1320.9
Survey; Caregiver
Form 10-0520, VA Form Survey, National Family
Training Participant
10-0541, VA Form 10- Caregiver Participant
Feedback; Income
0545, VA Form 10-0546 Training Feedback Form,
Verification Survey;
Survey of Veterans'
Non-VA Care Vet
Satisfaction with Income
Survey; Neuro-Rehab
Verification, Non-VA Care
Satisfaction Survey
Coordination Veteran
Satisfaction Survey,
Nuerology/Rehabilitation
Inpatient Program
Satisfaction Survey

Hrs/$/Resp
1,281 / 0 / 13,482

125 / 0 / 2,500

80 / 0 / 1,600

55 / 0 / 220

1,440 / 0 / 7,200

126 / 0 / 586

1,165 / 0 / 11,356

1,883 / 0 / 30,875

1,335 / 0 / 12,920

IC Title
Community Living
Center (CLC)
Satisfaction Survey;
Cardiac Cath Lab
Satisfaction Survey;
Psychiatric Patient
Survey
Survey of Veterans
Perceptions of an
Enhanced VA
Outpatient Prescription
Label
VCS Patriot Store/Cafe
Customer/VCS Focus
Group/Patient
Experience of Care
Survey/VA Dental
Service Customer
Survey/Mental Health
Satisfaction
PTSD Family Caregiver
Feedback/ARCH Focus
Group/VA Courtesy
Standards/PTSD Coach
(Phone) Apps Survey
Food and Nutrition
Survey/Fraud,Waste,Ab
use Complaint/Epilepsy
Satisf-Survey/Building
Better Caregivers
Survey/Sodium
Dichromate Feedback
Survey

Form No.

List of ICs
Form Name

CFR Citation

Hrs/$/Resp

VA Form 10-0548, VA Community Living Center 5 CFR 1320.8(d)
Form 10-0550, VA Form (CLC) Satisfaction Survey,
10-0547
Psychiatric Patient
Satisfaction Survey,
Cardiac Cath Lab
Customer Satisfaction
Survey
VA Form 10-0549
Rx Label Feedback

64 / 0 / 875

VA Form 10-0551, VA
Form 10-0553S, VA
form 10-0552, VA form
10-0553, VA Form 100554

2,632 / 0 / 11,765

VA Form 10-0495, VA
Form 10-0496, VA Form
10-0496a, VA Form 100497

5 CFR 1320.8(d)

VA Form 10-0559, VA Sodium Dichromate
5 CFR 1320.8(d)
Form 10-0558, VA Form Exposure Exam Feedback
10-0500, VA Form 10- Survey, Epilepsy Centers
0498, VA Form 10-0499 of Excellence (ECoE)
Patient Satisfaction
Survey, Fraud, Waste and
Abuse Complaint Form,
Food and Nutrition
Satisfaction Survey,
Building Better Caregivers
Satisfaction Survey
5 CFR 1230.8(d)

VHA Customer Value
Online Survey /
Customer Value Focus
Group
Vet Apptmnt Apps
Satisfaction Srvy/HemOncology Telehealth
Satisfaction Svy
DeBakey Home Care
VA Form 10-0480, VA
Satisfaction Survey /
Form 10-0476
CPEP Veterans
Satisfaction Survey

Compensation and
Pension Examination
Program (CPEP) Veterans
Satisfaction Survey,
Michael E. DeBakey
Patient Satisfaction
Survey
Patient Satisfaction
VA Form 10-10063, VA Patient Satisfaction
Surveys: Radiation
Form 10-10058
Survey- Radiation
Oncology/VISN 12
Oncology, Telephone
Telephone Care Service
Care Services Patient
Satisfaction Survey
Boston VAMC
VA Form 10-211001NR, Patient Satisfaction
Ophthamology
VA Form 10-10059
Survey_Boston
Satisfaction Survey /
VAMC_Dept. of
VISN 20 Telephone Call
Ophthamology, Telephone
Center Satisfaction
Customer Service
Survey
Experience Satisfaction
Survey

373 / 0 / 5,600

1,353 / 0 / 4,420

4,941 / 0 / 129,980

423 / 0 / 860

36 / 0 / 430

170 / 0 / 1,714

66 / 0 / 560

275 / 0 / 2,300

IC Title
Anticoagulation
(Warfarin/Coumadin)
Patient Satisfaction
Survey
MSCoE Patient
Survey/Project ARCH
Non-Participant
Survey/Wait Rm
Television Edu Survey

Form No.
VA Form 10-211002

List of ICs
Form Name

CFR Citation

Anticoagulation
(warfarin/Coumadin)
Patient Satisfaction
Survey
VA Form 10-211004,
PROJECT ARCH (Access
VA Form 10-211005,
Received Closer to Home)
VA Form 10-211003
Non-Participating
Veterans Survey, Patient
Survey: Waiting Room
Television Video Patient
Education, MSCoE
Patient Survey
Outpatient Pharmacy
VA Fform 10-211006NR Outpatient Pharmacy
5 CFR 1320.9
Customer Satisfaction
Customer Satisfaction
Survey
Survey
National Patient
10-211009, 10-211008 National Patient Centered
Centered Community
Community Care Veterans
Care Survey Questions
Survey Question, Dental
/ Oklahoma City (OKC)
(Ambulatory) Patient
VAMC Dental Patient
Satisfaction Survey
Satisfaction Survey
Rehabilitation Care
VA Form 10-211013,
HEC Enrollment Survey,
Survey/HEC Vet
VA Form 10-211010,
Survey of Rehabilitation
Enrollment
VA Form 10-211004
Care Survey, Project
Survey/Project ARCH
ARCH Non-Participant
non-sub change
Survey
HomeBased
VA Form 10-211013,
Non-VA-Purchased Care
PrimaryCare
VA Form 10-211014,
Veteran Survey, Home
Survey/Non-VA
VA Form 10-211011,
Based Primary Care
Purchased Care
VA Form 10-211016
Survey, Dental Insurance
Survey/Vet Dental
Program Survey, TeleInsurance
Dermatology Imaging
Survey/Teledermatolog
Patient Satisfaction
y Imaging Patient
Survey
Satisfaction Survey
Survey of Patient
VA Form 10-211015SP, Spanish version: Survey
Satisfaction at Surgical VA Form 10-211015
of Patient Satisfaction at
Service
Surgical Services, Survey
of Patient Satisfaction at
Surgical Service
VISN 1 Call Center
VA Form 10-211014a
Customer Service
Survey / OKC HB
Primary Care
Satisfaction Survey
Veterans Transportation
Service Questionnaire
CFM Supplier Electronic VA Form 10164, VA
CFM Supplier Electronic
Comment Card / CFM Form 10163
Comment Card, CFM
Supplier Satisfaction
Supplier Satisfaction
Survey
Survey
Total Hours Actually Used for Information Collections Under Currently Approved ICR:

Hrs/$/Resp
560 / 0 / 4,800

1,866 / 0 / 7,515

4 / 0 / 50
1,434 / 0 / 12,400

271 / 0 / 1,328

1,388 / 0 / 14,320

608 / 0 / 1,825

314 / 0 / 4,350

33 / 0 / 2,000
167 / 0 / 2,000

24,468