Information Collection

WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys

IC 247004 under ICR 202201-0917-001 · OMB 0917-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

2025-04-30 - Reinstatement without change of a previously approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys	Form and Instruction
1 Behavioral Health Patient Satisfaction Survey Behavioral Health Patient Satisfaction Survey 3-21.docx	Form and Instruction
1 Behavioral Health Patient Satisfaction Survey Behavioral Health Patient Satisfaction Survey 3-21.docx	Form and Instruction
2 Dental Patient Satisfaction Survey Dental Patient Satisfaction Survey 3-21.docx	Form and Instruction
2 Dental Patient Satisfaction Survey Dental Patient Satisfaction Survey 3-21.docx	Form and Instruction
3 Laboratory Patient Satisfaction Survey Laboratory Patient Satisfaction Survey 3-21.docx	Form and Instruction
3 Laboratory Patient Satisfaction Survey Laboratory Patient Satisfaction Survey 3-21.docx	Form and Instruction
4 Nutrition Services Patient Satisfaction Survey Nutrition Services Patient Satisfaction Survey 3-21.docx	Form and Instruction
4 Nutrition Services Patient Satisfaction Survey Nutrition Services Patient Satisfaction Survey 3-21.docx	Form and Instruction
5 Optometry Patient Satisfaction Survey Optometry Patient Satisfaction Survey 3-21.docx	Form and Instruction
5 Optometry Patient Satisfaction Survey Optometry Patient Satisfaction Survey 3-21.docx	Form and Instruction
6 Pharmacy Patient Satisfaction Survey Pharmacy Patient Satisfaction Survey 3-21.doc.docx	Form and Instruction
6 Pharmacy Patient Satisfaction Survey Pharmacy Patient Satisfaction Survey 3-21.doc.docx	Form and Instruction
7 Physcial Therapy Patient Satisfaction Survey Physical Therapy Patient Satisfaction Survey 3-21.doc.docx	Form and Instruction
7 Physcial Therapy Patient Satisfaction Survey Physical Therapy Patient Satisfaction Survey 3-21.doc.docx	Form and Instruction
8 Radiology Patient Satisfaction Survey Radiology Patient Satisfaction Survey 3-21.doc.docx	Form and Instruction
8 Radiology Patient Satisfaction Survey Radiology Patient Satisfaction Survey 3-21.doc.docx	Form and Instruction
Generic Clearance Submission Template - WWKMHCC 2-21.docx Generic Clearance Submission Template	IC Document
Generic Clearance Submission Template - WWKMHCC 2-21.docx Generic Clearance Submission Template	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER Satisfaction Surveys

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	Available Electronically?	Electronic Capability
Form and Instruction	1	Behavioral Health Patient Satisfaction Survey	Behavioral Health Patient Satisfaction Survey 3-21.docx	No	Paper Only
Form and Instruction	2	Dental Patient Satisfaction Survey	Dental Patient Satisfaction Survey 3-21.docx	No	Paper Only
Form and Instruction	3	Laboratory Patient Satisfaction Survey	Laboratory Patient Satisfaction Survey 3-21.docx	No	Paper Only
Form and Instruction	4	Nutrition Services Patient Satisfaction Survey	Nutrition Services Patient Satisfaction Survey 3-21.docx	No	Paper Only
Form and Instruction	5	Optometry Patient Satisfaction Survey	Optometry Patient Satisfaction Survey 3-21.docx	No	Paper Only
Form and Instruction	6	Pharmacy Patient Satisfaction Survey	Pharmacy Patient Satisfaction Survey 3-21.doc.docx	No	Paper Only
Form and Instruction	7	Physcial Therapy Patient Satisfaction Survey	Physical Therapy Patient Satisfaction Survey 3-21.doc.docx	No	Paper Only
Form and Instruction	8	Radiology Patient Satisfaction Survey	Radiology Patient Satisfaction Survey 3-21.doc.docx	No	Paper Only

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: 960

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	960	960
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Clearance Submission Template	Generic Clearance Submission Template - WWKMHCC 2-21.docx	04/23/2021

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