Information Collection

Patient Perception Survey (CC)

IC 225091 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⚠️ Notice: This information collection may be referencing outdated material.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 Patient Perception Survey (CC)	Form and Instruction
1 NIHAIP Survey Mock-up - NRC Health NIHAIP Survey Mock-up - NRC Health.pdf	Form and Instruction
2 NIHAOP Survey Mock-up - NRC Health NIHAOP Survey Mock-up - NRC Health.pdf	Form and Instruction
Fast Track Request under GC 0925-0648 CC Patient Perception Surveys.doc Fast Track Template for CC Patient Perception Survey	IC Document

IC Title:

Patient Perception 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	NIHAIP Survey Mock-up - NRC Health	NIHAIP Survey Mock-up - NRC Health.pdf		No		Paper Only
Form and Instruction	2	NIHAOP Survey Mock-up - NRC Health	NIHAOP Survey Mock-up - NRC Health.pdf		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,500	7,500
Annual IC Time Burden (Hours)	3,750	3,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track Template for CC Patient Perception Survey	Fast Track Request under GC 0925-0648 CC Patient Perception Surveys.doc	01/10/2017

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