Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)

Forms and Documents

Document Name	Status
Form OAWP 001 Office of Accountability and Whistleblower Protection Survey Form	New
Form C&P02 Veteran C&P [Compensation and Pension] Survey Form and Instruction	New
Form CSignals002 CSignals Caregiver Comment Card Form	New
Form 001 Community Pulse Check (CPC) Digital Comment Card Form	New
Form 10-xxxx Patient Centered Hand Hygiene Survey Form and Instruction	New
Form 10-211011 Survey of Veterans' Satisfaction with the VA Dental Insurance Program (VADIP) Form and Instruction	New
Form 10-10058 VISN 12 Telephone Care Services Satisfaction Survey Form and Instruction	New
Form 10-0515 1_Spinal Cord Injury Survey__2_Non-Sub Change-Veterans Experience Access (VE Outpatient Survey) Scheduling Appointment Form and Instruction	New
Form 10-0476 Michael DeBakey Satisfation Survey Form and Instruction	New
Form 10-0542 Spinal Cord Injury Home Care Patient Satisfaction Survey Form and Instruction	New
Form 10-0583 Purchased Care Patient Satisfaction Online Survey Form and Instruction	New
Form 10-0531 VHA Childcare Services Satisfaction Survey Form and Instruction	New
Form 10-0516 Network Consolidated Laboratory (NCL) Phlebotomy Service: Patient Satisfaction Questionnaire Form	New
Justification for Non-Substantive Change 2900-0770.docx Justification for No Material/Nonsubstantive Change	2017-10-02
30 Day FRN 2900-0770.pdf Supplementary Document	2017-08-01
60-Day FRN 2900-0770.pdf Supplementary Document	2017-07-26
Generic Fast-Track Clearance Request Template.docx Supplementary Document	2017-08-01
Qualitative Feedback Justification B.docx Supporting Statement B	2017-04-27
(NCA VBA VHA)-Qualitative_Feedback_Justification A 10-2-17.docx Supporting Statement A	2017-10-02

IC Document Collections

IC ID	Document Title	Status
242052	VISN 1 NCL Phlebotomy Service - Patient Satisfaction Survey Other-Survey	New
240147	Overton Brooks VAMC - ENT Department Survey Other-Survey	New
239637	Whole Health Patient Satisfaction Survey Other-survey	New
239118	Remote Veterans Apnea Management Platform (REVAMP) Customer Satisfaction Survey Other-Survey	New
238880	Office of Accountability and Whistleblower Protection Survey Form	New
238475	Veteran C&P [Compensation and Pension] Survey Form and Instruction	New
238195	VA Homeless Program - Customer Feedback Survey Other-Survey	New
237970	CSignals Caregiver Comment Card Form	New
237547	Nat'l Center on Homelessness Among Veterans - Customer Feedback Survey Other-Survey	New
237471	VA Loma Linda Healthcare System CBOC Clinics - Patient Satisfaction Survey Other-Survey	New
236889	TeleRehabilitation Enterprise Wide Initiative (TREWI) Patient Satisfaction Survey Other-Telephone Survey	New
236884	Project ATLAS (Advancing Telehealth through Local Access Stations) Telehealth Care Provider Survey Other-Survey	New
236636	Community Pulse Check (CPC) Digital Comment Card Form	New
236566	Revised MISSION Act Comment Card Other-Email Invitation and Reminder	New
236307	Mobile App Field Testing (VHA OCC) Other-Survey	New
236305	VHA Office of Connected Care (OCC) Mobile App Production Store Survey Other-Survey	New
236172	Home Monitoring for Early Detection of Chronic Disease Exacerbation (COPD) Other-Questionnaire	New
235759	Community Nursing Home (CNH) Dementia ECHO: Staff Education Evaluation Other-Questionnaire	New
235304	Patient Centered Hand Hygiene Survey Form and Instruction	New
235217	Update to VEO Outpatient Survey Instruction	New
234759	Survey of Veterans' Satisfaction with the VA Dental Insurance Program (VADIP) Form and Instruction	New
234461	CEDCC - Community Engagement Digital Comment Card Instruction	New
233933	NCA Memorial Affairs Survey/ NCA Scheduling Service Survey Instruction	New
233695	VHA Veteran Inpatient Services VEO Survey / VBA Contact Center Other-eSurvey	New
233222	HEC Enrollment Survey Other-Questionnaire	New
233148	Board of Veterans' Appeals VEO Surveys (NOD Filing/Hearing/Decision) Other-Survey	New
232847	Vets.gov Fast-track E-Survey Request Other-E-Survey	New
232754	Rehabilitation Care Services Satisfaction Survey Other-Survey	New
232508	Community Nursing Home Program Interviews Other-Interview	New
232311	VA Community Care Network Provider Satisfaction Survey for Regions 1, 2, 3 and 4 Other-Survey	New
232106	Income Verification Process Survey Other-Survey	New
232026	VISN 20 Specialty Access Initiative-Video Follow-Up Visits for Obstructive Sleep Apnea Therapy Other-Interview Guide	New
231907	Veterans Experience Office (VEO)_Board of Veterans Appeals Survey Other-Web Survey	New
231800	VetExperOffice_Telehealth Services Survey Other-Customer Satisfaction Survey	New
231680	Virtual Integrated Multisite Patient Alighted Care Team (V-IMPACT) Comprehensive Evaluation and Review Other-Interview	New
231505	Veterans Experience: Education Services VEO Survey Other-Survey	New
231418	1. VISN 1 Outpatient Mental Health Patient Satisfaction Survey / 2. VE NCA Survey_Non-Sub Change Other-Satisfaction Survey	New
231130	My HealtheVet Summative Usability Test / VE Non-Sub Change Request_WH HotlineCallSurvey Gender Other-Study Plan	New
230956	VA Community Care Provider Satisfaction Survey Other-Satisfaction Survey	New
230955	Veterans Choice Program Provider Satisfaction Survey Other-Satisfaction Survey	New
230954	Cooperative Studies Program Other-Study Site Survey	New
230936	VE: White House Hotline VA Veterans Call Center Online/Phone Survey Other-Survey and Script	New
230918	Virtual Nursing Visits to Evaluate Blood Pressure - Provider & Clinician Opinion Other-User Inquiry	New
230867	Pain Management ECHO Evaluation: Patient Perspective Other-Telephone Evaluation	New
230815	VHA Women Veterans Call Center Survey Other-Telephone Survey	New
230658	State Veteran Home Staff Interviews Other-Interviews	New
230323	VISN 1 CLC Patient Satisfaction Survey Other-Questionnaire	New
230273	Understanding Patient Perceptions of Access in VISN 22 Other-Interview Questions	New
230219	Veterans Experience Feedback Tool: E-Comment Card Other-Web: E-Comment Card	New
230206	VISN 12 Telephone Care Services Satisfaction Survey Form and Instruction	New
230197	VCS Customer Satisfaction Focus Groups Other-Focus Group Questionnaire	New
230108	1_Spinal Cord Injury Survey__2_Non-Sub Change-Veterans Experience Access (VE Outpatient Survey) Scheduling Appointment Form and Instruction	New
230107	Michael DeBakey Satisfation Survey Form and Instruction	New
229973	Digital Svc at VA Usability Research Participant Recruiting Screener Other-Questionnaire	New
229956	VISN 1 Call Centers Customer Satisfaction Survey Other-Telephone Survey	New
229922	Spinal Cord Injury Home Care Patient Satisfaction Survey Form and Instruction	New
229918	Purchased Care Patient Satisfaction Online Survey Form and Instruction	New
229760	MyVA Access Veteran Interviews Other-Interview	New
229680	Home Health Care Services Satisfaction Questionnaire Other-Questionnaire	New
229517	Hydration Satisfaction of Hines VA CLC Residents Other-Survey	New
229484	Medical Foster Home (MFH) Program Veteran Survey Other-Survey	New
229483	Medical Foster Home (MFH) Program Caregiver Survey Other-Survey	New
229482	Community Residential Care (CRC) Program Veteran Survey Other-Survey	New
229475	Income Verification Survey Other-Survey	New
229236	Veterans Experience: NCA Automated Phone Survey Other-Phone Survey	New
229220	Health Resource Center (HRC) Satisfaction Survey Other-Telephone Survey	New
229219	VHA Childcare Services Satisfaction Survey Form and Instruction	New
229196	Veterans Benefits Administration Veterans Success on Campus (VSOC) Survey Other-Survey	New
228925	VEO Disability Compensation Survey / VE Outpatient Survey Questions Non-Sub Change Request Other-E-Survey	New
228706	SORCC - Veterans Satisfaction Survey of Spiritual Care Needs Other-Survey	New
228703	Revised VE Outpatient Survey Other-E-Survey	New
228699	VA Pittsburgh Community Nursing Home Satisfaction Survey Other-Satisfaction Survey	New
228697	VISN 1 - Medical Center Solutions Call Centers Customer Satisfaction Survey Other-Telephone Script	New
228694	Health Advocate Pilot Project Patient Satisfaction Assessment Other-Assessment	New
228686	Network Consolidated Laboratory (NCL) Phlebotomy Service: Patient Satisfaction Questionnaire Form	New
228570	Veterans Experience Agency Priority Goal (APG) Trust Phone Survey Other-Phone Survey	New
228555	White House Hotline Call Center Email/Survey Other-Web Survey	New

ICR Details

OMB Control No: 2900-0770	ICR Reference No: 201710-2900-001
Status: Historical Active	Previous ICR Reference No: 201702-2900-010
Agency/Subagency: VA	Agency Tracking No: 2900-0770
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/03/2017
	Date Received in OIRA: 10/02/2017
Terms of Clearance: OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2020	09/30/2020	09/30/2020
Responses	335,000	0	335,000
Time Burden (Hours)	300,000	0	214,167
Cost Burden (Dollars)	0	0	0

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Abstract: The generic clearance will be used to collect qualitative feedback on VA's services or products delivery. VA will seek customer and stakeholder perceptions, experiences and expectations on its services or products delivery. The data collected will be used to improve delivery of products or services in areas where needed.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standard
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 20535	05/02/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 35876	08/01/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 77

IC Title	Form No.	Form Name
Income Verification Survey
Digital Svc at VA Usability Research Participant Recruiting Screener
1_Spinal Cord Injury Survey__2_Non-Sub Change-Veterans Experience Access (VE Outpatient Survey) Scheduling Appointment	10-0515	Spinal Cord Injury Patient Care Survey
VISN 20 Specialty Access Initiative-Video Follow-Up Visits for Obstructive Sleep Apnea Therapy
CEDCC - Community Engagement Digital Comment Card
Network Consolidated Laboratory (NCL) Phlebotomy Service: Patient Satisfaction Questionnaire	10-0516	Patient Satisfaction Questionnaire: Network Consolidated Laboratory (NCL) Phlebotomy Service
MyVA Access Veteran Interviews
Veterans Experience Feedback Tool: E-Comment Card
Virtual Nursing Visits to Evaluate Blood Pressure - Provider & Clinician Opinion
Veterans Experience Office (VEO)_Board of Veterans Appeals Survey
Revised MISSION Act Comment Card	001	MISSION Act Comment Card
Whole Health Patient Satisfaction Survey
State Veteran Home Staff Interviews
SORCC - Veterans Satisfaction Survey of Spiritual Care Needs
Health Advocate Pilot Project Patient Satisfaction Assessment
Veterans Experience: NCA Automated Phone Survey
VE: White House Hotline VA Veterans Call Center Online/Phone Survey
VetExperOffice_Telehealth Services Survey
Community Nursing Home Program Interviews
Mobile App Field Testing (VHA OCC)
Board of Veterans' Appeals VEO Surveys (NOD Filing/Hearing/Decision)
Veterans Benefits Administration Veterans Success on Campus (VSOC) Survey
Purchased Care Patient Satisfaction Online Survey	10-0583	Purchased Care Patient Satisfaction Online Survey
Vets.gov Fast-track E-Survey Request
Veterans Choice Program Provider Satisfaction Survey
White House Hotline Call Center Email/Survey
Hydration Satisfaction of Hines VA CLC Residents
Medical Foster Home (MFH) Program Veteran Survey
VISN 1 Call Centers Customer Satisfaction Survey
Understanding Patient Perceptions of Access in VISN 22
Update to VEO Outpatient Survey
Home Monitoring for Early Detection of Chronic Disease Exacerbation (COPD)
VISN 1 NCL Phlebotomy Service - Patient Satisfaction Survey
VA Homeless Program - Customer Feedback Survey
Remote Veterans Apnea Management Platform (REVAMP) Customer Satisfaction Survey
VA Community Care Provider Satisfaction Survey
Veterans Experience: Education Services VEO Survey
VEO Disability Compensation Survey / VE Outpatient Survey Questions Non-Sub Change Request
Medical Foster Home (MFH) Program Caregiver Survey
VISN 1 CLC Patient Satisfaction Survey
VISN 12 Telephone Care Services Satisfaction Survey	10-10058	Telephone Care Services Patient Satisfaction Survey
My HealtheVet Summative Usability Test / VE Non-Sub Change Request_WH HotlineCallSurvey Gender
Pain Management ECHO Evaluation: Patient Perspective
NCA Memorial Affairs Survey/ NCA Scheduling Service Survey
VHA Office of Connected Care (OCC) Mobile App Production Store Survey
Community Nursing Home (CNH) Dementia ECHO: Staff Education Evaluation
Community Pulse Check (CPC) Digital Comment Card	001, 001	CPC_SurveyWireframe2_v2_07162019.pdf ,   CPC_SurveyWireframe2_v2_withNewQuestion_061719
Nat'l Center on Homelessness Among Veterans - Customer Feedback Survey
Cooperative Studies Program
Veterans Experience Agency Priority Goal (APG) Trust Phone Survey
VISN 1 - Medical Center Solutions Call Centers Customer Satisfaction Survey
Revised VE Outpatient Survey
VA Pittsburgh Community Nursing Home Satisfaction Survey
Community Residential Care (CRC) Program Veteran Survey
Spinal Cord Injury Home Care Patient Satisfaction Survey	10-0542	Spinal Cord Injury – Home Care Patient Satisfaction Survey
Michael DeBakey Satisfation Survey	10-0476	Michael E. Debakey Home Care Program
Rehabilitation Care Services Satisfaction Survey
VHA Veteran Inpatient Services VEO Survey / VBA Contact Center
Income Verification Process Survey
Patient Centered Hand Hygiene Survey	10-xxxx, 10-xxxx	Patient Centered Hand Hygiene Survey Form ,   Semmelweis Hand Hygiene Survey Form - 6 per sheet
Project ATLAS (Advancing Telehealth through Local Access Stations) Telehealth Care Provider Survey
Office of Accountability and Whistleblower Protection Survey	OAWP 001	Office of Accountability and Whistleblower Protection Survey
1. VISN 1 Outpatient Mental Health Patient Satisfaction Survey / 2. VE NCA Survey_Non-Sub Change
HEC Enrollment Survey
Virtual Integrated Multisite Patient Alighted Care Team (V-IMPACT) Comprehensive Evaluation and Review
VHA Childcare Services Satisfaction Survey	10-0531	Childcare Services Satisfaction Survey
Health Resource Center (HRC) Satisfaction Survey
Home Health Care Services Satisfaction Questionnaire
VCS Customer Satisfaction Focus Groups
VHA Women Veterans Call Center Survey
Survey of Veterans' Satisfaction with the VA Dental Insurance Program (VADIP)	10-211011, 10-211011	Final Dental Survey ,   Department of Veterans Affairs Dental Insurance Program Survey
TeleRehabilitation Enterprise Wide Initiative (TREWI) Patient Satisfaction Survey
CSignals Caregiver Comment Card	CSignals002	CSignals Caregiver Comment Card
VA Loma Linda Healthcare System CBOC Clinics - Patient Satisfaction Survey
Overton Brooks VAMC - ENT Department Survey
Veteran C&P [Compensation and Pension] Survey	C&P02, VEO CP01, C&P02	CP Exam Survey Mock Up ,   C&P Exam Survey Mockup ,   C&P Exam E-Mail Mockup
VA Community Care Network Provider Satisfaction Survey for Regions 1, 2, 3 and 4

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	335,000	335,000	0	0	0	0
Annual Time Burden (Hours)	300,000	214,167	0	85,833	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The adjustment is being made due to the increased agency use of the flexibility of the Generic Fast-track. It is also due to the anticipated, extensive use by the VA's Veterans Experience program office, in efforts to develop and generate qualitative Customer Satisfaction surveys within the next 3 years, under the guise of the Office of the Secretary.

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Annual Cost to Federal Government: $350,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/02/2017

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