Patient Survey

Understanding Health System Approaches to Chronic Pain Management

Documents and Forms

Document Name Document Type
Form 0920- Patient Survey Form and Instruction
0920- Patient Survey Att. B Patient Survey.docx Form and Instruction
Att. J.1 Patient Survey Screen Shot.pdf Att J1_Screenshots_Patient Survey IC Document

Information Collection (IC) Details

IC Title:	Patient Survey	Agency IC Tracking Number:	0920-21IE

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-	Patient Survey	Att. B Patient Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 667	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	667	667
Annual IC Time Burden (Hours)	111	111
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att J1_Screenshots_Patient Survey	Att. J.1 Patient Survey Screen Shot.pdf	01/26/2022

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