Gallup Service Unit Patient Satisfaction Survey

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Document Name Document Type
Form 0917-0036-38 Gallup Service Unit Patient Satisfaction Survey Form and Instruction
0917-0036-38 OMB No. 0917-0036-38, Gallup Service Unit Patient Satisf OMB No. 0917-0036-38, Gallup Service Unit Patient Satisfaction Survey.doc Form and Instruction
OMB No 0917-0036-38, Mini-Supporting Statement for Patient Satisfaction Survey, Gallup Service Unit.doc OMB No. 0917-0036-38, Mini-Supporting Statement for GSU Patient Satisfaction Survey IC Document

Information Collection (IC) Details

IC Title:	Gallup Service Unit Patient Satisfaction Survey	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
Form and Instruction	0917-0036-38	OMB No. 0917-0036-38, Gallup Service Unit Patient Satisfaction Survey	OMB No. 0917-0036-38, Gallup Service Unit Patient Satisfaction Survey.doc		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,800	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	2,800	2,800
Annual IC Time Burden (Hours)	233	233
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
OMB No. 0917-0036-38, Mini-Supporting Statement for GSU Patient Satisfaction Survey	OMB No 0917-0036-38, Mini-Supporting Statement for Patient Satisfaction Survey, Gallup Service Unit.doc	04/08/2014

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