Information Collection

Patient Perception Surveys – Behavioral Health (CC)

IC 255318 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⚠️ Notice: This information collection may be referencing outdated material.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 Patient Perception Surveys – Behavioral Health (CC)	Form
1 Adult Inpatient Behavioral Health survey Adult Inpatient Behavioral Health Survey 8-3-22.docx	Form
2 Adult Outpatient Behavioral Health survey Adult Outpatient Behavioral Health Survey 8-3-22.docx	Form
3 Pediatric Inpatient Behavioral health survey Pediatric Inpatient Behavioral Health Survey 8-3-22.docx	Form
4 Pediatric Outpatient Behavioral Health survey Pediatric Outpatient Behavioral Health Survey 8-3-22.docx	Form
Fast Track Request under GC 0925-0648 CC Patient Perception Surveys 8-15-22 Behavioral Health.docx fast track template for Patient Behavioral Health survey	IC Document
Email Invitations to Participate in Patient Feedback Surveys.docx email invitation	IC Document

IC Title:

Patient Perception Surveys â Behavioral Health (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 Behavioral Health survey	Adult Inpatient Behavioral Health Survey 8-3-22.docx	Yes	Yes	Fillable Fileable
Form	2	Adult Outpatient Behavioral Health survey	Adult Outpatient Behavioral Health Survey 8-3-22.docx	Yes	Yes	Fillable Fileable
Form	3	Pediatric Inpatient Behavioral health survey	Pediatric Inpatient Behavioral Health Survey 8-3-22.docx	Yes	Yes	Fillable Fileable
Form	4	Pediatric Outpatient Behavioral Health survey	Pediatric Outpatient Behavioral Health Survey 8-3-22.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

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	1,200	1,200
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
fast track template for Patient Behavioral Health survey	Fast Track Request under GC 0925-0648 CC Patient Perception Surveys 8-15-22 Behavioral Health.docx	08/15/2022
email invitation	Email Invitations to Participate in Patient Feedback Surveys.docx	08/15/2022

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