Information Collection

Patient Exit Survey (English, Spanish & Creole)

IC 209258 under ICR 201311-0920-005 · OMB 0920-1002.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Patient Exit Survey (English, Spanish & Creole)	Form and Instruction
Appendix 10: Patient Exit Survey (Spanish) App 10 Patient Exit Survey (Spanish).docx	Form and Instruction
Appendix 11: Patient Exit Survey (Creole) App 11 Patient Exit Survey (Creole).docx	Form and Instruction
Appendix 9: Patient Exit Survey (English) App 9 Patient Exit Survey (English).docx	Form and Instruction

IC Title:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Appendix 10: Patient Exit Survey (Spanish)	App 10 Patient Exit Survey (Spanish).docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	Appendix 11: Patient Exit Survey (Creole)	App 11 Patient Exit Survey (Creole).docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	Appendix 9: Patient Exit Survey (English)	App 9 Patient Exit Survey (English).docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

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	1,200	1,200
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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