Information Collection

Patient survey

IC 196396 under ICR 201102-0935-002 · OMB 0935-0176.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #11 Patient survey	Form and Instruction
Form #11 Patient Survey Attachment Q -- Patient Survey 020411.doc	Form and Instruction
Attachment R -- Invitation to Participate in Patient Survey 020411.doc Attachment R -- Invitation to Participate in Patient Survey 020411	IC Document

IC Title:

Patient survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #11	Patient Survey	Attachment Q -- Patient Survey 020411.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 884

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,768	1,768
Annual IC Time Burden (Hours)	884	884
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment R -- Invitation to Participate in Patient Survey 020411	Attachment R -- Invitation to Participate in Patient Survey 020411.doc	02/10/2011

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