Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care

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⚠️ Notice: This information collection may be referencing outdated material.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 10-0450 Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care Form and Instruction
10-0450 Veterans Choice Program Survey VCP Survey 030215_For OMB Submission_v6 updated (3)CLEAN.docx Form and Instruction
10-0455 Nationwide Dialysis Program Survey Nationwide Dialysis Contracts Program Veterans Survey.docx Form and Instruction
10-0457 VLER Program Survey VLER Exchange_Undecided Vet Interview Guide_011315.docx Form and Instruction
10-0552 Patient Experience of Care Survey Patient Experiences Survey_10-0552.doc Form and Instruction
OMB fast track for VA VCP 3.2.15_updated CLEAN.doc Veterans Choice Program Fast Track Request IC Document
Nationwide Dialysis Contracts Veterans Survey Information Collection Package 20141212.docx Nationwide Dialysis Program Fast Track Request IC Document
VLER _Generic_Clearance_Request Form 01_20_15.docx VLER Fast Track Request IC Document
Generic_Submission_Request EM Patient Survey.docx Generic Clearance Request - Patient Experience Survey IC Document

Information Collection (IC) Details

IC Title:	Veterans Choice Program, Nationwide Dialysis Contracts, VLER User Survey, Healthcare User survey, Patient Experience of Care	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	10-0450	Veterans Choice Program Survey	VCP Survey 030215_For OMB Submission_v6 updated (3)CLEAN.docx	No	Fillable Printable
Form and Instruction	10-0455	Nationwide Dialysis Program Survey	Nationwide Dialysis Contracts Program Veterans Survey.docx	No	Fillable Printable
Form and Instruction	10-0457	VLER Program Survey	VLER Exchange_Undecided Vet Interview Guide_011315.docx	No	Fillable Printable
Form and Instruction	10-0552	Patient Experience of Care Survey	Patient Experiences Survey_10-0552.doc	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,045	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	10,045	10,045
Annual IC Time Burden (Hours)	1,339	1,339
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Veterans Choice Program Fast Track Request	OMB fast track for VA VCP 3.2.15_updated CLEAN.doc	03/06/2015
Nationwide Dialysis Program Fast Track Request	Nationwide Dialysis Contracts Veterans Survey Information Collection Package 20141212.docx	03/06/2015
VLER Fast Track Request	VLER _Generic_Clearance_Request Form 01_20_15.docx	03/06/2015
Generic Clearance Request - Patient Experience Survey	Generic_Submission_Request EM Patient Survey.docx	03/26/2015

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