Information Collection

Health Information Technology Patient Satisfaction Survey (CC)

IC 223699 under ICR 201501-0925-004 · OMB 0925-0648.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0648 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Health Information Technology Patient Satisfaction Survey (CC)	Form and Instruction
1 Patient Portal Online Survey Screenshot Patient Portal Online Survey Screenshots 9 23 2016 w OMB control and exp date Final.docx	Form and Instruction
Fast Track Request under GC 0925-0648 CC Portal Survey 9 22 2016 NP (2).doc Health Information Technology Patient Satisfaction Survey (CC)	IC Document

IC Title:

Health Information Technology Patient Satisfaction Survey (CC)

Agency IC Tracking Number:

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 Portal Online Survey Screenshot	Patient Portal Online Survey Screenshots 9 23 2016 w OMB control and exp date Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

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	3,000	3,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Health Information Technology Patient Satisfaction Survey (CC)	Fast Track Request under GC 0925-0648 CC Portal Survey 9 22 2016 NP (2).doc	09/26/2016

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