Information Collection

Patient Services Survey

IC 213555 under ICR 202008-0906-002 · OMB 0906-0004.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0004 can be found here:

Documents and Forms

Document Name Document Type
Form 1 E C Patient Services Survey Form and Instruction
1 E C Survey - Be The Match CLEAN.docx FORM Survey - Be The Match CLEAN.docx Form and Instruction
1 E R Survey - Be The Match REDLINE.docx FORM Survey - Be The Match REDLINE.docx Form and Instruction
1 S C Spanish Survey - Be The Match CLEAN.docx FORM Spanish Survey - Be The Match CLEAN.docx.docx Form and Instruction
1 S R Spanish Survey- Be The Match REDLINE.docx FORM Spanish Survey- Be The Match REDLINE.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Patient Services Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	1 E C	Survey - Be The Match CLEAN.docx	FORM Survey - Be The Match CLEAN.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1 E R	Survey - Be The Match REDLINE.docx	FORM Survey - Be The Match REDLINE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1 S C	Spanish Survey - Be The Match CLEAN.docx	FORM Spanish Survey - Be The Match CLEAN.docx.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1 S R	Spanish Survey- Be The Match REDLINE.docx	FORM Spanish Survey- Be The Match REDLINE.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,320	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	Previously Approved
Annual Number of Responses for this IC	1,320	900	420
Annual IC Time Burden (Hours)	220	115	105
Annual IC Cost Burden (Dollars)	0	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.