Patient Perception Survey- Non-Behavioral (CC)

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIH)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0648 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Patient Perception Survey- Non-Behavioral (CC) Form
1 Adult and Pediatric Outpatient Services Survey Adult and Pediatric Outpatient Services Survey.docx Form
1 Adult and Pediatric Outpatient Services Survey Adult and Pediatric Outpatient Services Survey.docx Form
2 Adult and Pediatric Outpatient Survey Adult and Pediatric Outpatient Survey.docx Form
2 Adult and Pediatric Outpatient Survey Adult and Pediatric Outpatient Survey.docx Form
Fast track request for CC Patient Perception Survey Non-Behavioral.docx Patient Perception Survey- Non-Behavioral (CC) IC Document
Fast track request for CC Patient Perception Survey Non-Behavioral.docx Patient Perception Survey- Non-Behavioral (CC) IC Document
Introductory Email-Login-Welcome Message (1).docx Introductory email-Logon-Welcome Message IC Document
Introductory Email-Login-Welcome Message (1).docx Introductory email-Logon-Welcome Message IC Document

Information Collection (IC) Details

IC Title:	Patient Perception Survey- Non-Behavioral (CC)	Agency IC Tracking Number:

IC Status: New

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	1	Adult and Pediatric Outpatient Services Survey	Adult and Pediatric Outpatient Services Survey.docx		Yes	Yes	Fillable Fileable
Form	2	Adult and Pediatric Outpatient Survey	Adult and Pediatric Outpatient Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51,600	51,600
Annual IC Time Burden (Hours)	4,300	4,300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Patient Perception Survey- Non-Behavioral (CC)	Fast track request for CC Patient Perception Survey Non-Behavioral.docx	04/01/2021
Introductory email-Logon-Welcome Message	Introductory Email-Login-Welcome Message (1).docx	04/01/2021

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