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⚠️ Notice: This information collection may be referencing outdated material.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 Inpatient Survey Adult Inpatient Survey (1).docx Form
1 Adult Inpatient Survey Adult Inpatient Survey (1).docx Form
2 Pediatric Inpatient Survey Pediatric Inpatient Survey.docx Form
2 Pediatric Inpatient Survey Pediatric Inpatient Survey.docx Form
3 Adult and Pediatric Survey Procedure Survey Adult and Pediatric Surgery-Procedure Survey.docx Form
3 Adult and Pediatric Survey Procedure Survey Adult and Pediatric Surgery-Procedure Survey.docx Form
Fast Track Request Patient Perception Surveys FINAL.docx Patient Perception Survey- Non-Behavioral (CC) IC Document
Fast Track Request Patient Perception Surveys FINAL.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	Available Electronically?	Electronic Capability
Form	1	Adult Inpatient Survey	Adult Inpatient Survey (1).docx	No	Paper Only
Form	2	Pediatric Inpatient Survey	Pediatric Inpatient Survey.docx	No	Paper Only
Form	3	Adult and Pediatric Survey Procedure Survey	Adult and Pediatric Surgery-Procedure Survey.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	39,200	39,200
Annual IC Time Burden (Hours)	3,267	3,267
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Patient Perception Survey- Non-Behavioral (CC)	Fast Track Request Patient Perception Surveys FINAL.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.