Patient Satisfaction Questionnaire

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIAID)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Patient Satisfaction Questionnaire	Agency IC Tracking Number:

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 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 %

	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

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.