Outpatient-Healthcare Visit-Adding Whole Health Questions

Clearance for A-11 Section 280 Improving Customer Experience Information Collection

Documents and Forms

Document Name Document Type
Outpatient Health Care Visit - Adding Whole Health Questions.docx Other-Survey Instrument
ICR Template_A11 Section 280 Clearance Outpatient Healthcare Visit Adding Whole Health Questions.docx ICR Template A11 Section 280 Clearance Outpatient Healthcare Visit Adding Whole Health Questions IC Document

Information Collection (IC) Details

IC Title:	Outpatient-Healthcare Visit-Adding Whole Health Questions	Agency IC Tracking Number:	2900-0876

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-Survey Instrument			Outpatient Health Care Visit - Adding Whole Health Questions.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Veterans, Dependents of Veterans, and Veteran Beneficiaries	FR Citation: 86 FR 6992

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
ICR Template A11 Section 280 Clearance Outpatient Healthcare Visit Adding Whole Health Questions	ICR Template_A11 Section 280 Clearance Outpatient Healthcare Visit Adding Whole Health Questions.docx	01/12/2026

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