Information Collection

Patient Survey

IC 251282 under ICR 202201-0920-014 · OMB 0920-1374.

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.