Information Collection

Attachment D – Patient Experience Survey_Data collection instrument

IC 227745 under ICR 202009-0935-001 · OMB 0935-0239.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Attachment D – Patient Experience Survey_Data collection instrument	Form and Instruction
2 Patient experience survey Attachment D_Patient Experience Survey_Data collection instrument_20170727.docx	Form and Instruction
2 Patient experience survey Attachment D_Patient Exp Survey_Data clean.docx	Form and Instruction
Attachment C_Patient Experience Survey_Cover letter and reminder notice_20170727.docx Attachment C – Patient Experience Survey_Cover letter and reminder notice	IC Document
Attachment C_Patient Experience Survey_Cover letter and reminder notice_20170727.docx Attachment C – Patient Experience Survey_Cover letter and reminder notice	IC Document

IC Title:

Attachment D â Patient Experience Survey_Data collection instrument

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	2	Patient experience survey	Attachment D_Patient Exp Survey_Data clean.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 980

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	980	-820	1,800
Annual IC Time Burden (Hours)	363	-303	666
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment C â Patient Experience Survey_Cover letter and reminder notice	Attachment C_Patient Experience Survey_Cover letter and reminder notice_20170727.docx	07/28/2017

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