Attachment C – Partner Hospital Champion Survey

Evaluating the Implementation of PCOR to Increase Referral, Enrollment, and Retention through Automatic Referral to Cardiac Rehabilitation (CR) with Care Coordinator

Documents and Forms

Document Name Document Type
Form 1 Attachment C – Partner Hospital Champion Survey Form and Instruction
1 Attachment C – Partner Hospital Champion Survey Attachment C. Partner Hospital Champion Survey (2020-01-08).docx Form and Instruction

Information Collection (IC) Details

IC Title:	Attachment C – Partner Hospital Champion Survey	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	1	Attachment C – Partner Hospital Champion Survey	Attachment C. Partner Hospital Champion Survey (2020-01-08).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 113	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	226	226
Annual IC Time Burden (Hours)	170	170
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.