Information Collection

Patient Centered Medical Home (PCMH) Staff Satisfaction Survey

IC 214366 under ICR 201412-0720-001 · OMB 0720-0059.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
PCMH SSS with Contractors - Screenshots.pdf	Other-Survey
DHA Patient Centered Medical Home Survey invite.doc	Other-Email Invite
Service PCMH Leads Memo.doc	Other-Memo Reminder
DMDC-recommendation-letter-PCMH-Staff-Satisfaction-Survey-OMB-Dec-18-2013.pdf	Other-DMDC Survey Review Memo

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey	PCMH SSS with Contractors - Screenshots.pdf	Yes	Yes	Fillable Fileable
Other-Email Invite	DHA Patient Centered Medical Home Survey invite.doc	Yes	Yes	Fillable Fileable
Other-Memo Reminder	Service PCMH Leads Memo.doc	Yes	Yes	Fillable Fileable
Other-DMDC Survey Review Memo	DMDC-recommendation-letter-PCMH-Staff-Satisfaction-Survey-OMB-Dec-18-2013.pdf	Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,105

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	3,105	3,105
Annual IC Time Burden (Hours)	518	518
Annual IC Cost Burden (Dollars)	15,525	15,525

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.