Information Collection

Patient Outcome Survey

IC 197078 under ICR 201103-0935-001 · OMB 0935-0178.

Documents and Forms

Document Name Document Type
Form Form #9 Patient Outcome Survey Form and Instruction
Form #9 Patient Outcome Survey Attachment J - Patient Outcomes Survey .doc Form and Instruction
Form #9 Patient Outcome Survey - Spanish Attachment J2- Patient Outcomes Survey - Spanish 5-10-2011.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Patient Outcome Survey	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	Form #9	Patient Outcome Survey	Attachment J - Patient Outcomes Survey .doc		Yes	Yes	Paper Only
Form and Instruction	Form #9	Patient Outcome Survey - Spanish	Attachment J2- Patient Outcomes Survey - Spanish 5-10-2011.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: 90	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	180	180
Annual IC Time Burden (Hours)	30	30
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.