Survey of Patient Satisfaction at Surgical Service

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⚠️ Notice: This information collection may be referencing outdated material.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 10-211015 Survey of Patient Satisfaction at Surgical Service Form
VA Form 10-211015 Survey of Patient Satisfaction at Surgical Service Surgical Patient Satisfaction Survey_10-211015.pdf Form
VA Form 10-211015S Spanish version: Survey of Patient Satisfaction at Surgi Spanish_version Surgical Survey_10-211015SP.pdf Form
Generic Request_Surgical Patient Satisfaction Survey 1-14.docx Generic Request Surgical Patient Satisfaction Survey 1-2014 IC Document
Daily Schedule of Surgery Sample.pdf Daily Schedule of Surgery Sample IC Document

Information Collection (IC) Details

IC Title:	Survey of Patient Satisfaction at Surgical Service	Agency IC Tracking Number:

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 10-211015	Survey of Patient Satisfaction at Surgical Service	Surgical Patient Satisfaction Survey_10-211015.pdf		No		Paper Only
Form	VA Form 10-211015SP	Spanish version: Survey of Patient Satisfaction at Surgical Services	Spanish_version Surgical Survey_10-211015SP.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,825	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	1,825	1,825
Annual IC Time Burden (Hours)	608	608
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Generic Request Surgical Patient Satisfaction Survey 1-2014	Generic Request_Surgical Patient Satisfaction Survey 1-14.docx	01/22/2014
Daily Schedule of Surgery Sample	Daily Schedule of Surgery Sample.pdf	01/22/2014

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