Outpatient Services Surveys

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⚠️ Notice: This information collection may be referencing outdated material.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-V1 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

Information Collection (IC) Details

IC Title:	Outpatient Services Surveys	Agency IC Tracking Number:	2900-0876-V

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.