Information Collection

2022 Patient Perception Inpatient Surveys (CC)

IC 251425 under ICR 202307-0925-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 2022 Patient Perception Inpatient Surveys (CC)	Form
1 Adult Inpatient Survey Revised with Discharge Question Adult Inpatient Survey Revised w Discharge Questions.docx	Form
2 Pediatric Inpatient Survey Pediatric Inpatient Survey Updated Screen Shots.docx	Form
3 Adult and Pediatric Surgery-Procedure Survey Adult and Pediatric Surgery-Procedure Survey Updated Screen Shots.docx	Form
01 Fast Track Request Patient Perception Inpatient Survey Non Behavioral Health FINAL.docx fast track for 2022 Patient Perception Inpatient Survey	IC Document
Introductory Email-Login-Welcome Message.docx Introductory email	IC Document

IC Title:

2022 Patient Perception Inpatient Surveys (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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Adult Inpatient Survey Revised with Discharge Question	Adult Inpatient Survey Revised w Discharge Questions.docx	Yes	Yes	Fillable Fileable
Form	2	Pediatric Inpatient Survey	Pediatric Inpatient Survey Updated Screen Shots.docx	Yes	Yes	Fillable Fileable
Form	3	Adult and Pediatric Surgery-Procedure Survey	Adult and Pediatric Surgery-Procedure Survey Updated Screen Shots.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	39,200	39,200
Annual IC Time Burden (Hours)	3,267	3,267
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
fast track for 2022 Patient Perception Inpatient Survey	01 Fast Track Request Patient Perception Inpatient Survey Non Behavioral Health FINAL.docx	02/03/2022
Introductory email	Introductory Email-Login-Welcome Message.docx	02/03/2022

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