Information Collection

Purchased Care Patient Satisfaction Online Survey

IC 229918 under ICR 201710-2900-001 · OMB 2900-0770.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0770 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-0583 Purchased Care Patient Satisfaction Online Survey	Form and Instruction
10-0583 Purchased Care Patient Satisfaction Online Survey Purchased Care Patient Satisfaction Survey_10-0538.docx	Form and Instruction
Purchased Care Online Survey_Generic Request.docx Generic Request_Purchased Care Patient Satisfaction	IC Document

IC Title:

Purchased Care Patient Satisfaction Online Survey

Agency IC Tracking Number:

2900-0770

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	10-0583	Purchased Care Patient Satisfaction Online Survey	Purchased Care Patient Satisfaction Survey_10-0538.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,800

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	4,800	4,800
Annual IC Time Burden (Hours)	960	960
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Request_Purchased Care Patient Satisfaction	Purchased Care Online Survey_Generic Request.docx	01/31/2018

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