Information Collection

Patient Perception Surveys – Behavioral Health (CC)

IC 246553 under ICR 202103-0925-003 · OMB 0925-0648.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Patient Perception Surveys – Behavioral Health (CC)	Form and Instruction
1 Adult Inpatient Behavioral Health Survey Adult Inpatient Behavioral Health Survey 16028-PY0101-644053-English - US_1.pdf	Form and Instruction
1 Adult Inpatient Behavioral Health Survey Adult Inpatient Behavioral Health Survey 16028-PY0101-644053-English - US_1.pdf	Form and Instruction
2 Adult Outpatient Behavioral Health Survey Adult Outpatient Behavioral Health Survey 16028-OY0101-644076-English - US_1.pdf	Form and Instruction
2 Adult Outpatient Behavioral Health Survey Adult Outpatient Behavioral Health Survey 16028-OY0101-644076-English - US_1.pdf	Form and Instruction
3 Pediatric Inpatient Behavioral Health Survey Pediatric Inpatient Behavioral Health Survey 16028-PY0102-644069-English - US_1.pdf	Form and Instruction
3 Pediatric Inpatient Behavioral Health Survey Pediatric Inpatient Behavioral Health Survey 16028-PY0102-644069-English - US_1.pdf	Form and Instruction
4 Pediatric Outpatient Behavioral Health Survey Pediatric Outpatient Behavioral Health Survey 16028-OY0102-646330-English - US_1.pdf	Form and Instruction
4 Pediatric Outpatient Behavioral Health Survey Pediatric Outpatient Behavioral Health Survey 16028-OY0102-646330-English - US_1.pdf	Form and Instruction
Fast Track Request under GC 0925-0648 CC Patient Perception Surveys March 24 2021 Behavioral Health FINAL.docx Patient Perception Surveys – Behavioral Health (CC)	IC Document
Fast Track Request under GC 0925-0648 CC Patient Perception Surveys March 24 2021 Behavioral Health FINAL.docx Patient Perception Surveys – Behavioral Health (CC)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Patient Perception Surveys â Behavioral Health (CC)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Adult Inpatient Behavioral Health Survey	Adult Inpatient Behavioral Health Survey 16028-PY0101-644053-English - US_1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2	Adult Outpatient Behavioral Health Survey	Adult Outpatient Behavioral Health Survey 16028-OY0101-644076-English - US_1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	3	Pediatric Inpatient Behavioral Health Survey	Pediatric Inpatient Behavioral Health Survey 16028-PY0102-644069-English - US_1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	4	Pediatric Outpatient Behavioral Health Survey	Pediatric Outpatient Behavioral Health Survey 16028-OY0102-646330-English - US_1.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: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Patient Perception Surveys â Behavioral Health (CC)	Fast Track Request under GC 0925-0648 CC Patient Perception Surveys March 24 2021 Behavioral Health FINAL.docx	04/01/2021

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