KSN Annual Feedback Survey Year 3

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (HITRC)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0955-0003 can be found here:

Documents and Forms

Document Name Document Type
0955-0003 KSN Annual Survey Instrument year 4 to AHRQ and ONC 10_31_13.docx Other-survey
0955-0003 GENERIC Submission REC Web Survey 9 7 12 (2).docx 0955-0003 GENERIC Submission REC Web Survey 9 7 12 (2) IC Document
0955-0003 Request Reminders to Take Web Survey_to AHRQ and ONC 10_ .docx 0955-0003 Request Reminders to Take Web Survey_to AHRQ and ONC 10_ IC Document

Information Collection (IC) Details

IC Title:	KSN Annual Feedback Survey Year 3	Agency IC Tracking Number:

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			0955-0003 KSN Annual Survey Instrument year 4 to AHRQ and ONC 10_31_13.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 326	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	326	0	0	0	0	0
Annual IC Time Burden (Hours)	38	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
0955-0003 GENERIC Submission REC Web Survey 9 7 12 (2)	0955-0003 GENERIC Submission REC Web Survey 9 7 12 (2).docx	11/08/2013
0955-0003 Request Reminders to Take Web Survey_to AHRQ and ONC 10_	0955-0003 Request Reminders to Take Web Survey_to AHRQ and ONC 10_ .docx	11/08/2013

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