Information Collection

Healthcare Organization Survey

IC 220390 under ICR 202102-0920-003 · OMB 0920-1129.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Healthcare Organization Survey	Form
Healthcare Organization Survey Q7 Healthcare Organization Utilization Survey.pdf	Form
Healthcare Organization Survey Q7 Healthcare Organization Utilization Survey.pdf	Form
G8 Healthcare Organization Utilization Survey.docx Healthcare Organization Survey - word	IC Document
G8 Healthcare Organization Utilization Survey.docx Healthcare Organization Survey - word	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	none	Healthcare Organization Survey	Q7 Healthcare Organization Utilization Survey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 234

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-234	234
Annual IC Time Burden (Hours)	-117	117
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Healthcare Organization Survey - word	G8 Healthcare Organization Utilization Survey.docx	03/02/2016

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