Information Collection

QI Program User Survey

IC 259196 under ICR 202009-0935-002 · OMB 0935-0179.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0179 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Survey Instrument – QI Software Users QI Program User Survey	Form
1 Survey Instrument – QI Software Users Draft survey instrument - QI software users 3_9_23_KHC.docx	Form
Fast Track 0935-0179 - QI Survey_feedback 1.docx Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”	IC Document

IC Title:

QI Program User Survey

Agency IC Tracking Number:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Not Required

FR Citation: 85 FR 113

Number of Respondents: 400

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	400	400
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval under the âGeneric Clearance for the Collection of Routine Customer Feedbackâ		03/16/2023

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

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