Information Collection

Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division

IC 228948 under ICR 201709-0935-001 · OMB 0935-0179.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0179 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	Form and Instruction
1 Patient Key Informants Customer Satisfaction Survey_Patient FINAL.docx	Form and Instruction
OMB Cover Letter_patientKI.doc Cover Letter	IC Document
Generic Clearance Submission Patient Questions FINAL.doc Supporting Statement	IC Document

IC Title:

Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division

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	Patient Key Informants	Customer Satisfaction Survey_Patient FINAL.docx		Yes	Yes	Fillable Fileable

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: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter	OMB Cover Letter_patientKI.doc	11/07/2017
Supporting Statement	Generic Clearance Submission Patient Questions FINAL.doc	11/07/2017

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