Information Collection

Telebehavioral Health Patient Satisfaction Survey

IC 225049 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 0917-0036 Telebehavioral Health Patient Satisfaction Survey Form
0917-0036 Telebehavioral Health Patient Satisfaction Survey Catawba Service Unit Telebehavioral Health Survey.docx Form
Telebehavioral Health Survey Request for Approval Form.docx Request for Approval - Telebehavioral Health Patient Satisfaction Survey IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Telebehavioral Health Patient Satisfaction Survey	Agency IC Tracking Number:	53

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0917-0036	Telebehavioral Health Patient Satisfaction Survey	Catawba Service Unit Telebehavioral Health Survey.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 1

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval - Telebehavioral Health Patient Satisfaction Survey	Telebehavioral Health Survey Request for Approval Form.docx	01/06/2017

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