No Show Survey

Clearance for A-11 Section 280 Improving Customer Experience Information Collection

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0876 can be found here:

Documents and Forms

Document Name Document Type
Form 2900-0876-003 No Show Survey Form and Instruction
2900-0876-003 No Show Survey Questions Established Patients No-Show - Established Patient Survey Wireframe.pdf Form and Instruction
2900-0876-004 No Show Survey Questions New Patients No-Show - New Patient Survey Wireframe.pdf Form and Instruction
A-11 Fast-Track Clearance Request Template_No Show_ (006)_.docx ICR Request Form IC Document
No Show Sampling Plan.docx Survey Sample Methodology IC Document

Information Collection (IC) Details

IC Title:	No Show Survey	Agency IC Tracking Number:	202003-2900-011

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	2900-0876-003	No Show Survey Questions Established Patients	No-Show - Established Patient Survey Wireframe.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-004	No Show Survey Questions New Patients	No-Show - New Patient Survey Wireframe.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,969	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,969	6,969
Annual IC Time Burden (Hours)	348	348
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
ICR Request Form	A-11 Fast-Track Clearance Request Template_No Show_ (006)_.docx	05/18/2020
Survey Sample Methodology	No Show Sampling Plan.docx	05/18/2020

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