Information Collection

Access to Care Survey Questionnaire

IC 207889 under ICR 201307-2900-011 · OMB 2900-0824.

Documents and Forms

Document Name Document Type
Form VA Form 10-10067 Access to Care Survey Questionnaire Form and Instruction
VA Form 10-10067 Access to Care Survey Questionnaire VA form 10-10067_Access to Care Questionnaire(2-27-14) (v3)-OMB Comments HM(3).docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Access to Care Survey 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
Form and Instruction	VA Form 10-10067	Access to Care Survey Questionnaire	VA form 10-10067_Access to Care Questionnaire(2-27-14) (v3)-OMB Comments HM(3).docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	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	20	20
Annual IC Time Burden (Hours)	10	10
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.