Information Collection

Patient Survey Instrument

IC 206893 under ICR 201305-0915-003 · OMB 0915-0368.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0368 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Patient Survey Instrument	Form and Instruction
1 Patient Survey 2014 HC Patient_Survey_01APRIL2013 (2).docx	Form and Instruction
2014 Health Center Patient Survey Cognitive Protocol Intro.doc 2014 Health Center Patient Survey Cognitive Protocol Intro	IC Document
Consent forms (3).doc Consent forms (3)	IC Document
Incentive Receipt.doc Incentive Receipt	IC Document

IC Title:

Patient Survey Instrument

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	1	Patient Survey	2014 HC Patient_Survey_01APRIL2013 (2).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 69

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	69	69
Annual IC Time Burden (Hours)	86	86
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
2014 Health Center Patient Survey Cognitive Protocol Intro	2014 Health Center Patient Survey Cognitive Protocol Intro.doc	05/09/2013
Consent forms (3)	Consent forms (3).doc	05/09/2013
Incentive Receipt	Incentive Receipt.doc	05/09/2013

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