Information Collection

2022 Patient Perception Outpatient Surveys (CC)

IC 251427 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⚠️ Notice: This information collection may be referencing outdated material.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 Outpatient Surveys (CC)	Form
1 Adult and Pediatric Outpatient Survey Adult and Pediatric Outpatient Survey Updated Screen Shots (1).docx	Form
2 Adult and Pediatric Outpatient Services Survey Adult and Pediatric Outpatient Services Survey Updated Screen Shots.docx	Form
02 Fast Track Template Patient Perception Outpatient Survey.docx fast track for 2022 Patient Perception Outpatient Survey	IC Document
Introductory Email-Login-Welcome Message.docx introductory email	IC Document

IC Title:

2022 Patient Perception Outpatient 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Adult and Pediatric Outpatient Survey	Adult and Pediatric Outpatient Survey Updated Screen Shots (1).docx		Yes	Yes	Fillable Fileable
Form	2	Adult and Pediatric Outpatient Services Survey	Adult and Pediatric Outpatient Services 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: 12,900

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	51,600	51,600
Annual IC Time Burden (Hours)	4,300	4,300
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 Outpatient Survey	02 Fast Track Template Patient Perception Outpatient Survey.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.