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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.