Information Collection

QI Program User Survey

IC 259196 under ICR 202310-0935-001 · OMB 0935-0179.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0179 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 QI Program User Survey	Form
1 Survey Instrument – QI Software Users Draft survey instrument - QI software users 3_9_23_KHC.docx	Form
1 Survey Instrument – QI Software Users Draft survey instrument - QI software users 3_9_23_KHC.docx	Form
Fast Track 0935-0179 - QI Survey_feedback 1.docx Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”	IC Document
Fast Track 0935-0179 - QI Survey_feedback 1.docx Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”	IC Document

IC Title:

QI Program User Survey

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	Survey Instrument â QI Software Users	Draft survey instrument - QI software users 3_9_23_KHC.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Not Required

FR Citation: 85 FR 113

Number of Respondents: 400

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	400	400
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval under the âGeneric Clearance for the Collection of Routine Customer Feedbackâ	Fast Track 0935-0179 - QI Survey_feedback 1.docx	03/16/2023

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