Information Collection

Self-Query Survey

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

Documents and Forms

Documents and forms in this information collection
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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.