Information Collection

Attachment B: Child HCAHPS Database Data Use Agreement

IC 235457 under ICR 201903-0935-002 · OMB 0935-0243.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0243 can be found here:

Documents and Forms

Document Name Document Type
Form 2 Attachment B: Child HCAHPS Database Data Use Agreement Form and Instruction
2 Attachment B: Child HCAHPS Database Data Use Agreement Attachment B Data Use Agreement Draft.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Attachment B: Child HCAHPS Database Data Use Agreement	Agency IC Tracking Number:

Is this a Common Form? No		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	2	Attachment B: Child HCAHPS Database Data Use Agreement	Attachment B Data Use Agreement Draft.pdf		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: Not-for-profit institutions, Businesses or other for-profits

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)	15	15
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.