Information Collection

PT/OT (Therapy Department) - Provision of Care Survey

IC 221047 under ICR 201504-0917-007 · OMB 0917-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0917-0036 PT/OT (Therapy Department) - Provision of Care Survey	Form and Instruction
0917-0036 PT/OT (Therapy Department) - Provision of Care Survey OMB 0917-0036-60 Therapy Patient Experience Survey Form, Joshua Mistic, 04-12-2016.docx	Form and Instruction

IC Title:

PT/OT (Therapy Department) - Provision of Care Survey

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	0917-0036	PT/OT (Therapy Department) - Provision of Care Survey	OMB 0917-0036-60 Therapy Patient Experience Survey Form, Joshua Mistic, 04-12-2016.docx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 350

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	350	350
Annual IC Time Burden (Hours)	18	18
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.