Vital Signs 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⚠️ Notice: This information collection may be referencing outdated material.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 0920-0956 can be found here:

Documents and Forms

Document Name Document Type
Vital Signs Survey Form and Instruction
Vital Signs Survey VS_screenshots.docx Form and Instruction
Vital Signs Survey Vital Signs Surveyv2.docx Form and Instruction
Survey1template _VitalSignsv2.docx Survey1template _VitalSignsv2 IC Document

Information Collection (IC) Details

IC Title:	Vital Signs 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	None	Vital Signs Survey	VS_screenshots.docx		Yes	Yes	Fillable Fileable
Form and Instruction	None	Vital Signs Survey	Vital Signs Surveyv2.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	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	3,000	0	0	0	0	0
Annual IC Time Burden (Hours)	351	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Survey1template _VitalSignsv2	Survey1template _VitalSignsv2.docx	06/11/2013

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