Information Collection

Patient Survey

IC 202538 under ICR 201205-0935-003 · OMB 0935-0202.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #6 Patient Survey Patient Survey	Form and Instruction
Form #6 Patient Survey Attachment I.1 -- Patient Survey.docx	Form and Instruction
Attachment I.2 -- Patient Survey Cover Memo-Tablet.docx Attachment I	IC Document
Attachment I.3 -- Patient Survey Cover memo-Paper.docx Attachment I	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 #6				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

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	1,200	1,200
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment I		05/30/2012
Attachment I		05/30/2012

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

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