Information Collection

Bereaved Family Member Satisfaction Survey

IC 178992 under ICR 201202-2900-006 · OMB 2900-0701.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0701 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 10-21081(N Bereaved Family Member Satisfaction Survey Form
VA Form 10-21081(N Bereaved Family Member Satisfaction Survey_Administered Bereaved Family Member Satisfaction Survey_Administered by Facility Staff.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Bereaved Family Member Satisfaction Survey	Agency IC Tracking Number:

Is this a Common Form? No		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 10-21081(NR)	Bereaved Family Member Satisfaction Survey_Administered by Facility Staff	Bereaved Family Member Satisfaction Survey_Administered by Facility Staff.doc		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11,000	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	Previously Approved
Annual Number of Responses for this IC	11,000	1,100	9,900
Annual IC Time Burden (Hours)	1,833	183	1,650
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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