Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QI) Customer Survey

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 1 Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QI) Customer Survey Form and Instruction
1 Web-based Survey Customer Satisfaction Survey_Patient FINAL.docx Form and Instruction
OMB Clearance Attachment B Submission Form AHRQ QI survey_FINALMD_5.09.2018.docx Supporting Statement IC Document
Cover Letter.doc Cover Letter IC Document

Information Collection (IC) Details

IC Title:	Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QI) Customer Survey	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	Web-based Survey	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: 300	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	OMB Clearance Attachment B Submission Form AHRQ QI survey_FINALMD_5.09.2018.docx	10/31/2018
Cover Letter	Cover Letter.doc	10/31/2018

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