Patient Services Survey

Be the Match® Patient Services Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0004 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Patient Services Survey Form and Instruction
1 CLEAN Office of Patient Advocacy Survey OMB revised 12-1 CLEAN Office of Patient Advocacy Survey OMB revised 12-13-17.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Patient Services Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	CLEAN Office of Patient Advocacy Survey OMB revised 12-13-17.docx	CLEAN Office of Patient Advocacy Survey OMB revised 12-13-17.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 420	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	420	420
Annual IC Time Burden (Hours)	105	105
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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