Information Collection

Point of Care Patient Questionnaire

IC 203111 under ICR 201207-2900-003 · OMB 2900-0796.

Documents and Forms

Document Name Document Type
POC Patient Phone Script.docx Other-Telephone Survey Script
VA Form 10-10069 Research Questionnaire POC Research Questionnaire 10-10069_9-2013.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Point of Care Patient Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		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
Other-Telephone Survey Script			POC Patient Phone Script.docx	N/A	No		Paper Only
Form	VA Form 10-10069	Research Questionnaire	POC Research Questionnaire 10-10069_9-2013.pdf	TBD	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	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	600	600
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	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.