Information Collection

Patient Satisfaction Questionnaire

IC 220902 under ICR 201512-0925-005 · OMB 0925-0668.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0668 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Patient Satisfaction Questionnaire	Form and Instruction
1 Home Questionaire PSQ 18HOME.pdf	Form and Instruction
2 NIH Questionaire PSQ 18NIH.pdf	Form and Instruction
NIAID LCID Fast Track Application.doc Fast-Track Template	IC Document

IC Title:

Patient Satisfaction Questionnaire

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	Home Questionaire	PSQ 18HOME.pdf		No		Paper Only
Form and Instruction	2	NIH Questionaire	PSQ 18NIH.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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	200	200
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast-Track Template	NIAID LCID Fast Track Application.doc	04/06/2016

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