Information Collection

Patient Services Survey

IC 213555 under ICR 201410-0906-001 · OMB 0906-0004.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0004 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Patient Services Survey	Form and Instruction
1 Patient Services Survey Be The Match Patient Services Survey.docx	Form and Instruction

IC Title:

Patient Services Survey

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 Services Survey	Be The Match Patient Services Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 420

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	420	420
Annual IC Time Burden (Hours)	105	105
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.