VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction

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⚠️ Notice: This information collection may be referencing outdated material.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 10-0551 VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction Form
VCS Focus Group Training Script.doc Other-Training Script
Script forMental Health Satisfaction Survey final[1].doc Other-Information Script
VA Form 10-0551 VCS Patriot Store and VCS Patriot Cafe Customer Satisfac VCS Patriot Store_Cafe Survey Form 10-0551.doc Form
VA form 10-0552 Patient Experience of Care Survey Patient Experiences Survey_10-0552.doc Form
VA form 10-0553 Dental Service Customer Satisfaction Survey 10-0553_Dental_Satisfaction_Survey_(English_Version)10-20121.docx Form
VA Form 10-0553S Dental Satisfaction Survey (Spanish version) 10-0553S_Encuesta Satisfaccion de Pacientes Dental (2).docx Form
VA Form 10-0554 Office of Mental Health Veteran Satisfaction Survey 10-0554_OMH Veteran Survey_July 2012_final.doc Form
Generic_Request VCS Surveys[1].docx Generic_Request VCS Surveys IC Document
Generic Submission-VCS Focus Groups.docx Generic Submission-VCS Focus Group IC Document
Generic_Submission_Request EM Patient Survey[1].docx Generic_Submission_Request EM Patient Survey IC Document
Dental Survey Generic_Submission_Template (3)[1].docx Dental Survey Generic Clearance Submission IC Document
Mental_Health_Generic_Clearance_Submission_final (2).docx Mental Health Veteran Satisfaction Generic_Request IC Document

Information Collection (IC) Details

IC Title:	VCS Patriot Store/Cafe Customer/VCS Focus Group/Patient Experience of Care Survey/VA Dental Service Customer Survey/Mental Health Satisfaction	Agency IC Tracking Number:	2900-0770

IC Status: Modified

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 10-0551	VCS Patriot Store and VCS Patriot Cafe Customer Satisfaction Survey	VCS Patriot Store_Cafe Survey Form 10-0551.doc		No		Paper Only
Other-Training Script			VCS Focus Group Training Script.doc		No		Paper Only
Form	VA form 10-0552	Patient Experience of Care Survey	Patient Experiences Survey_10-0552.doc		No		Paper Only
Form	VA form 10-0553	Dental Service Customer Satisfaction Survey	10-0553_Dental_Satisfaction_Survey_(English_Version)10-20121.docx		No		Paper Only
Form	VA Form 10-0553S	Dental Satisfaction Survey (Spanish version)	10-0553S_Encuesta Satisfaccion de Pacientes Dental (2).docx		No		Paper Only
Form	VA Form 10-0554	Office of Mental Health Veteran Satisfaction Survey	10-0554_OMH Veteran Survey_July 2012_final.doc	TBD	Yes	Yes	Fillable Fileable
Other-Information Script			Script forMental Health Satisfaction Survey final[1].doc	TBD	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11,765	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	11,765	11,765
Annual IC Time Burden (Hours)	2,632	2,632
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Generic_Request VCS Surveys	Generic_Request VCS Surveys[1].docx	09/24/2012
Generic Submission-VCS Focus Group	Generic Submission-VCS Focus Groups.docx	09/24/2012
Generic_Submission_Request EM Patient Survey	Generic_Submission_Request EM Patient Survey[1].docx	09/24/2012
Dental Survey Generic Clearance Submission	Dental Survey Generic_Submission_Template (3)[1].docx	09/24/2012
Mental Health Veteran Satisfaction Generic_Request	Mental_Health_Generic_Clearance_Submission_final (2).docx	10/05/2012

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