Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME 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⚠️ Notice: This information collection may be referencing outdated material.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 10-10122 Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey Form and Instruction
10-10122 HME Vendor Performance Survey HME Vendor Performance Survey 2014 (CR 8 22 14).docx Form and Instruction
10-10123 MH Veteran Survey MH Veteran Survey (CR 8 21 14).docx Form and Instruction
10-10126 Patient Satisfaction Survey Prothetics Customer survey FY14 (CR 8 22 14 v2).docx Form and Instruction
10-10125 Prosthetics Customer Service Survey Prothetics Customer survey FY14 (CR 8 21 14 v1)-3.docx Form and Instruction
Prosthesis Fast-Track Clearance Request.pdf HME Fast Track IC Document
Prosthesis Fast-Track Clearance Request.pdf Patient Satisfaction Survey Fast Track IC Document
ProthesticsCustomer Fast-Track Clearance Request.pdf Internal Satisfaction Fast Track IC Document
VeteransSurvey2014application.docx MH Survey Fast Track IC Document

Information Collection (IC) Details

IC Title:	Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey	Agency IC Tracking Number:	2900-0770

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	10-10122	HME Vendor Performance Survey	HME Vendor Performance Survey 2014 (CR 8 22 14).docx	No	Fillable Printable
Form and Instruction	10-10123	MH Veteran Survey	MH Veteran Survey (CR 8 21 14).docx	No	Fillable Printable
Form and Instruction	10-10126	Patient Satisfaction Survey	Prothetics Customer survey FY14 (CR 8 22 14 v2).docx	No	Fillable Printable
Form and Instruction	10-10125	Prosthetics Customer Service Survey	Prothetics Customer survey FY14 (CR 8 21 14 v1)-3.docx	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,160	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	3,160	3,160
Annual IC Time Burden (Hours)	1,317	1,317
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
HME Fast Track	Prosthesis Fast-Track Clearance Request.pdf	08/21/2014
Patient Satisfaction Survey Fast Track	Prosthesis Fast-Track Clearance Request.pdf	08/21/2014
Internal Satisfaction Fast Track	ProthesticsCustomer Fast-Track Clearance Request.pdf	08/21/2014
MH Survey Fast Track	VeteransSurvey2014application.docx	08/21/2014

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