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⚠️ Notice: This information collection may be referencing outdated material.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

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:

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 %

	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

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.