Information Collection

Health Information Technology Patient Satisfaction Survey (CC)

IC 230121 under ICR 202104-0925-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Health Information Technology Patient Satisfaction Survey (CC)	Form
1 Patient Portal Online Survey Screenshot Patient Portal Online Survey Screenshots 9 23 2016 w OMB control and exp date Final.docx	Form
1 Patient Portal Online Survey Screenshot Patient Portal Online Survey Screenshots 9 23 2016 w OMB control and exp date Final.docx	Form
Fast Track Request under GC 0925-0648 CC Portal Survey 9 22 2016 NP (2).doc Fast track Health Information Technology Patient Satisfaction Survey (CC)	IC Document
Fast Track Request under GC 0925-0648 CC Portal Survey 9 22 2016 NP (2).doc Fast track Health Information Technology Patient Satisfaction Survey (CC)	IC Document

IC Title:

Health Information Technology Patient Satisfaction Survey (CC)

Agency IC Tracking Number:

IC Status: Unchanged

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	1	Patient Portal Online Survey Screenshot	Patient Portal Online Survey Screenshots 9 23 2016 w OMB control and exp date Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

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	Previously Approved
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast track Health Information Technology Patient Satisfaction Survey (CC)	Fast Track Request under GC 0925-0648 CC Portal Survey 9 22 2016 NP (2).doc	02/14/2018

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