EOHSI/Rutgers Clinical Center of Excellence Annual Monitoring Exam Patient Satisfaction 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⚠️ Notice: This information collection may be referencing outdated material.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 0920-0953 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0953 EOHSI/Rutgers Clinical Center of Excellence Annual Monitoring Exam Patient Satisfaction Survey Form and Instruction
0920-0953 Rutgers Patient Satisfaction Survey 2019 Rutgers Patient Satisfaction Survey 2019.pdf Form and Instruction
OMB Fast Track Submission__Rugters_061819.docx Fasttrack Submission Template IC Document

Information Collection (IC) Details

IC Title:	EOHSI/Rutgers Clinical Center of Excellence Annual Monitoring Exam Patient Satisfaction Survey	Agency IC Tracking Number:	0920-0953-19BIA

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	0920-0953	Rutgers Patient Satisfaction Survey 2019	Rutgers Patient Satisfaction Survey 2019.pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,100	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	2,100	2,100
Annual IC Time Burden (Hours)	175	175
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Fasttrack Submission Template	OMB Fast Track Submission__Rugters_061819.docx	06/21/2019

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