Information Collection

Patient Services Survey

IC 213555 under ICR 202306-0906-001 · OMB 0906-0004.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0004 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Patient Services Survey	Form and Instruction
1 OPA PSC Survey English 05122023 - OPA PSC Survey English - Burden Statement - OMB 0906-0004.docx	Form and Instruction
1 OPA PSC Survey English 05122023 - OPA PSC Survey English - Burden Statement - OMB 0906-0004.docx	Form and Instruction
2 OPA PSC Survey - Spanish 05122023 - OPA PSC Survey Spanish - Burden Statement - OMB 0906-0004.docx	Form and Instruction
2 OPA PSC Survey - Spanish 05122023 - OPA PSC Survey Spanish - Burden Statement - OMB 0906-0004.docx	Form and Instruction

IC Title:

Patient Services Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1	OPA PSC Survey English	05122023 - OPA PSC Survey English - Burden Statement - OMB 0906-0004.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2	OPA PSC Survey - Spanish	05122023 - OPA PSC Survey Spanish - Burden Statement - OMB 0906-0004.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	900	-420	1,320
Annual IC Time Burden (Hours)	153	-67	220
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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