Information Collection

No Show Survey

IC 241855 under ICR 202003-2900-011 · OMB 2900-0876.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

No Show Survey

Agency IC Tracking Number:

202003-2900-011

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.