Information Collection

Outpatient Services Surveys

IC 243253 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⚠️ Notice: This information collection may be referencing outdated material.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-V1 Outpatient Healthcare Visit Outpatient Services Surveys	Form and Instruction
Form 2900-0876-V4 Pharmacy by Mail Outpatient Services Surveys	Form and Instruction
Form 2900-0876-V5 Pharmacy in Person Outpatient Services Surveys	Form and Instruction
Form 2900-0876-V3 Labs and Imaging Outpatient Services Surveys	Form and Instruction
Form 2900-0876-V2 Scheduling an Appointment Outpatient Services Surveys	Form and Instruction
2900-0876-V1 Outpatient Healthcare Visit OPT Healthcare Visit.pdf	Form and Instruction
2900-0876-V4 Pharmacy by Mail OPT Pharmacy Mail.pdf	Form and Instruction
2900-0876-V5 Pharmacy in Person OPT Pharmacy In-Person.pdf	Form and Instruction
2900-0876-V3 Labs and Imaging OPT Labs Imaging.pdf	Form and Instruction
2900-0876-V2 Scheduling an Appointment Scheduling An Appointment survey.pdf	Form and Instruction
A-11 Fast-Track Clearance Request Template_Outpatient_.pdf A-11 Generic Clearance Requirements Document	IC Document
Service Level Measurement - Outpatient Sampling Plan June 2018_v4.docx Survey Sample Plan	IC Document

IC Title:

Outpatient Services Surveys

Agency IC Tracking Number:

2900-0876-V

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2900-0876-V1	Outpatient Healthcare Visit	OPT Healthcare Visit.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-V4	Pharmacy by Mail	OPT Pharmacy Mail.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-V5	Pharmacy in Person	OPT Pharmacy In-Person.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-V3	Labs and Imaging	OPT Labs Imaging.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-V2	Scheduling an Appointment	Scheduling An Appointment survey.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,835,048

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	7,835,048	7,835,048
Annual IC Time Burden (Hours)	391,752	391,752
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
A-11 Generic Clearance Requirements Document	A-11 Fast-Track Clearance Request Template_Outpatient_.pdf	08/19/2020
Survey Sample Plan	Service Level Measurement - Outpatient Sampling Plan June 2018_v4.docx	08/19/2020

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