Survey of Patients' Perceptions of the Impact of Third Party Billing on Clinical Research Participation

Generic Clearance for Surveys of Customers and other Partners (CC)

Documents and Forms

Document Name Document Type
Form 1 Survey of Patients' Perceptions of the Impact of Third Party Billing on Clinical Research Participation Form and Instruction
1 Third Party Billing Survey 3rd Party Survey Questions OMB Submission.docx Form and Instruction
Mini Supporting Statement CC Third Party Billing.docx Mini Supporting Statement CC Third Party Billing IC Document

Information Collection (IC) Details

IC Title:	Survey of Patients' Perceptions of the Impact of Third Party Billing on Clinical Research Participation	Agency IC Tracking Number:

IC Status: Unchanged

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	Third Party Billing Survey	3rd Party Survey Questions OMB Submission.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Mini Supporting Statement CC Third Party Billing	Mini Supporting Statement CC Third Party Billing.docx	06/05/2013

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