Information Collection

Self-Query Survey

IC 207741 under ICR 202102-0915-002 · OMB 0915-0366.

Documents and Forms

Document Name Document Type
Form 2 Self-Query Survey Form and Instruction
2 Self Query Respondents survey screenshots.pdf FORM Attachment 13 Self Query Respondents survey screenshots.pdf Form and Instruction
2 Self Query Respondents survey screenshots.pdf FORM Attachment 13 Self Query Respondents survey screenshots.pdf Form and Instruction
Attachment 11 Self query survey codebook 1-21.pdf Attachment 11 Self query survey codebook 1-21 IC Document
Attachment 11 Self query survey codebook 1-21.pdf Attachment 11 Self query survey codebook 1-21 IC Document
Attachment 16 Email self querier.docx Attachment 16 Email self querier IC Document
Attachment 16 Email self querier.docx Attachment 16 Email self querier IC Document
1 Welcome Page.docx 1 Welcome Page IC Document
1 Welcome Page.docx 1 Welcome Page IC Document
2 Demographics Intro.docx 2 Demographics Intro IC Document
2 Demographics Intro.docx 2 Demographics Intro IC Document
3 Individuals - Demographics.docx 3 Individuals - Demographics IC Document
3 Individuals - Demographics.docx 3 Individuals - Demographics IC Document
4 Individuals - Query intro.docx 4 Individuals - Query intro IC Document
4 Individuals - Query intro.docx 4 Individuals - Query intro IC Document
5 Individuals - Query experiences.docx 5 Individuals - Query experiences IC Document
5 Individuals - Query experiences.docx 5 Individuals - Query experiences IC Document
6 Individuals - Report intro.docx 6 Individuals - Report intro IC Document
6 Individuals - Report intro.docx 6 Individuals - Report intro IC Document
7 Individuals - Report experiences.docx 7 Individuals - Report experiences IC Document
7 Individuals - Report experiences.docx 7 Individuals - Report experiences IC Document
8 Individuals - Dispute intro.docx 8 Individuals - Dispute intro IC Document
8 Individuals - Dispute intro.docx 8 Individuals - Dispute intro IC Document
9 Individuals - Dispute experience .docx 9 Individuals - Dispute experience IC Document
9 Individuals - Dispute experience .docx 9 Individuals - Dispute experience IC Document
10 Individuals - Perceptions.docx 10 Individuals - Perceptions IC Document
10 Individuals - Perceptions.docx 10 Individuals - Perceptions IC Document
11 Individuals - Satisfaction with products and services.docx 11 Individuals - Satisfaction with products and services IC Document
11 Individuals - Satisfaction with products and services.docx 11 Individuals - Satisfaction with products and services IC Document
12 Organizations - Demographics.docx 12 Organizations - Demographics IC Document
12 Organizations - Demographics.docx 12 Organizations - Demographics IC Document
13 Organizations - Query intro.docx 13 Organizations - Query intro IC Document
13 Organizations - Query intro.docx 13 Organizations - Query intro IC Document
14 Organizations - Query experiences.docx 14 Organizations - Query experiences IC Document
14 Organizations - Query experiences.docx 14 Organizations - Query experiences IC Document
15 Organization - Report intro.docx 15 Organization - Report intro IC Document
15 Organization - Report intro.docx 15 Organization - Report intro IC Document
16 Organizations - Report experiences.docx 16 Organizations - Report experiences IC Document
16 Organizations - Report experiences.docx 16 Organizations - Report experiences IC Document
17 Organizations - Dispute intro.docx 17 Organizations - Dispute intro IC Document
17 Organizations - Dispute intro.docx 17 Organizations - Dispute intro IC Document
18 Organizations - Dispute experience.docx 18 Organizations - Dispute experience IC Document
18 Organizations - Dispute experience.docx 18 Organizations - Dispute experience IC Document
19 Organizations - Perceptions.docx 19 Organizations - Perceptions IC Document
19 Organizations - Perceptions.docx 19 Organizations - Perceptions IC Document
20 Organizations - Satisfaction with products and services.docx 20 Organizations - Satisfaction with products and services IC Document
20 Organizations - Satisfaction with products and services.docx 20 Organizations - Satisfaction with products and services IC Document
21 NPDB HIPDB Merger.docx 21 NPDB HIPDB Merger IC Document
21 NPDB HIPDB Merger.docx 21 NPDB HIPDB Merger IC Document
22 End comments.docx 22 End comments IC Document
22 End comments.docx 22 End comments IC Document
SelfQuery_Flowchart.pdf SelfQuery_Flowchart IC Document
SelfQuery_Flowchart.pdf SelfQuery_Flowchart IC Document
SelfQuery_Flowchart_June_2020.pdf SelfQuery_Flowchart_June_2020 IC Document
SelfQuery_Flowchart_June_2020.pdf SelfQuery_Flowchart_June_2020 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Self-Query 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	Self Query Respondents survey screenshots.pdf	FORM Attachment 13 Self Query Respondents survey screenshots.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	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	2,000	2,000
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 11 Self query survey codebook 1-21	Attachment 11 Self query survey codebook 1-21.pdf	02/11/2021
Attachment 16 Email self querier	Attachment 16 Email self querier.docx	02/11/2021
1 Welcome Page	1 Welcome Page.docx	02/11/2021
2 Demographics Intro	2 Demographics Intro.docx	02/11/2021
3 Individuals - Demographics	3 Individuals - Demographics.docx	02/11/2021
4 Individuals - Query intro	4 Individuals - Query intro.docx	02/11/2021
5 Individuals - Query experiences	5 Individuals - Query experiences.docx	02/11/2021
6 Individuals - Report intro	6 Individuals - Report intro.docx	02/11/2021
7 Individuals - Report experiences	7 Individuals - Report experiences.docx	02/11/2021
8 Individuals - Dispute intro	8 Individuals - Dispute intro.docx	02/11/2021
9 Individuals - Dispute experience	9 Individuals - Dispute experience .docx	02/11/2021
10 Individuals - Perceptions	10 Individuals - Perceptions.docx	02/11/2021
11 Individuals - Satisfaction with products and services	11 Individuals - Satisfaction with products and services.docx	02/11/2021
12 Organizations - Demographics	12 Organizations - Demographics.docx	02/11/2021
13 Organizations - Query intro	13 Organizations - Query intro.docx	02/11/2021
14 Organizations - Query experiences	14 Organizations - Query experiences.docx	02/11/2021
15 Organization - Report intro	15 Organization - Report intro.docx	02/11/2021
16 Organizations - Report experiences	16 Organizations - Report experiences.docx	02/11/2021
17 Organizations - Dispute intro	17 Organizations - Dispute intro.docx	02/11/2021
18 Organizations - Dispute experience	18 Organizations - Dispute experience.docx	02/11/2021
19 Organizations - Perceptions	19 Organizations - Perceptions.docx	02/11/2021
20 Organizations - Satisfaction with products and services	20 Organizations - Satisfaction with products and services.docx	02/11/2021
21 NPDB HIPDB Merger	21 NPDB HIPDB Merger.docx	02/11/2021
22 End comments	22 End comments.docx	02/11/2021
SelfQuery_Flowchart	SelfQuery_Flowchart.pdf	02/11/2021
SelfQuery_Flowchart_June_2020	SelfQuery_Flowchart_June_2020.pdf	02/11/2021

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