Purchased Care Patient Satisfaction Online 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⚠️ Notice: This information collection may be referencing outdated material.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 10-0583 Purchased Care Patient Satisfaction Online Survey Form and Instruction
10-0583 Purchased Care Patient Satisfaction Online Survey Purchased Care Patient Satisfaction Survey_10-0538.docx Form and Instruction
Purchased Care Online Survey_Generic Request.docx Generic Request_Purchased Care Patient Satisfaction IC Document

Information Collection (IC) Details

IC Title:	Purchased Care Patient Satisfaction Online 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-0583	Purchased Care Patient Satisfaction Online Survey	Purchased Care Patient Satisfaction Survey_10-0538.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,800	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	4,800	4,800
Annual IC Time Burden (Hours)	960	960
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Generic Request_Purchased Care Patient Satisfaction	Purchased Care Online Survey_Generic Request.docx	01/31/2018

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