Information Collection

SSG Fox SPGP - Intake Form

IC 253143 under ICR 202601-2900-003 · OMB 2900-0904.

Documents and Forms

Document Name Document Type
Form 10-317b SSG Fox SPGP - Intake Form SSG Fox SPGP - Intake Form Form and Instruction
10-317b SSG Fox SPGP - Intake Form VA Form 10-317b_Intake Form_SPGP_updated 2026.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SSG Fox SPGP - Intake Form	Agency IC Tracking Number:	2900-0904

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 and Instruction	10-317b	SSG Fox SPGP - Intake Form	VA Form 10-317b_Intake Form_SPGP_updated 2026.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 90	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	16,200	16,200
Annual IC Time Burden (Hours)	2,700	2,700
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.

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