Information Collection

Attachment D – Patient Experience Survey_Data collection instrument

IC 227745 under ICR 201707-0935-004 · OMB 0935-0239.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0239 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Attachment D – Patient Experience Survey_Data collection instrument	Form and Instruction
2 Patient experience survey Attachment D_Patient Experience Survey_Data collection instrument_20170727.docx	Form and Instruction
Attachment C_Patient Experience Survey_Cover letter and reminder notice_20170727.docx Attachment C – Patient Experience Survey_Cover letter and reminder notice	IC Document

IC Title:

Attachment D â Patient Experience Survey_Data collection instrument

Agency IC Tracking Number:

Is this a Common Form? No

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	2	Patient experience survey	Attachment D_Patient Experience Survey_Data collection instrument_20170727.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,800

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	1,800	1,800
Annual IC Time Burden (Hours)	666	666
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment C â Patient Experience Survey_Cover letter and reminder notice	Attachment C_Patient Experience Survey_Cover letter and reminder notice_20170727.docx	07/28/2017

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