Consumer/Patient Survey

Evaluation of ARRA Comparative Effectiveness Research Dissemination Contractor Efforts

Documents and Forms

Document Name Document Type
Form Form #3 Consumer/Patient Survey Form and Instruction
Form #3 Consumer or Patient Questionnaire Attachment D -- Consumer or Patient Questionnaire.doc Form and Instruction
Attachment E -- Consumer or Patient Repondent Materials.doc Attachment E -- Consumer or Patient Repondent Materials IC Document

Information Collection (IC) Details

IC Title:	Consumer/Patient 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 #3	Consumer or Patient Questionnaire	Attachment D -- Consumer or Patient Questionnaire.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	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	2,000	2,000
Annual IC Time Burden (Hours)	667	667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment E -- Consumer or Patient Repondent Materials	Attachment E -- Consumer or Patient Repondent Materials.doc	11/30/2011

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