Information Collection

Use of Narrative Data to Explore Disparities in Patient Experience

IC 262196 under ICR 202309-0935-001 · OMB 0935-0266.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 Use of Narrative Data to Explore Disparities in Patient Experience	Form and Instruction
Form #1 Survey Instrument Attachment B Survey Instrument 042523.docx	Form and Instruction
Form #1 Survey Instrument Attachment B Survey Instrument 042523.docx	Form and Instruction
Attachment A CG-CAHPS NEP Invitation 042523.docx CG-CAHPS NEP Invitation	IC Document
Attachment A CG-CAHPS NEP Invitation 042523.docx CG-CAHPS NEP Invitation	IC Document
Attachment C Informed Consent 042523.docx Informed Consent	IC Document
Attachment C Informed Consent 042523.docx Informed Consent	IC Document
Attachment D Ipsos Confidentiality Agreement 021023.docx Ipsos Confidentiality Agreement	IC Document
Attachment D Ipsos Confidentiality Agreement 021023.docx Ipsos Confidentiality Agreement	IC Document

IC Title:

Agency IC Tracking Number:

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	Form #1	Survey Instrument	Attachment B Survey Instrument 042523.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,998

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,998	4,998
Annual IC Time Burden (Hours)	1,416	1,416
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CG-CAHPS NEP Invitation	Attachment A CG-CAHPS NEP Invitation 042523.docx	09/15/2023
Informed Consent	Attachment C Informed Consent 042523.docx	09/15/2023
Ipsos Confidentiality Agreement	Attachment D Ipsos Confidentiality Agreement 021023.docx	09/15/2023

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