Patient Survey Instrument

Health Center Patient Survey

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.