Information Collection

Patient and Caregiver Survey

IC 263757 under ICR 202401-0935-006 · OMB 0935-0124.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Patient and Caregiver Survey	Form and Instruction
1 Patient and Caregiver Survey Patient and Caregiver Survey.docx	Form and Instruction
1 Patient and Caregiver Survey Patient and Caregiver Survey.docx	Form and Instruction
eCarePlan Consent Information Sheet - SURVEY.pdf eCarePlan Consent Information Sheet - SURVEY	IC Document
eCarePlan Consent Information Sheet - SURVEY.pdf eCarePlan Consent Information Sheet - SURVEY	IC Document
fast-track-PRA-submission-short-form Patient and Caregiver Survey.docx fast-track-PRA-submission-short-form Patient and Caregiver Survey	IC Document
fast-track-PRA-submission-short-form Patient and Caregiver Survey.docx fast-track-PRA-submission-short-form Patient and Caregiver Survey	IC Document

IC Title:

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 and Instruction	1	Patient and Caregiver Survey	Patient and Caregiver Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 90

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	90	90
Annual IC Time Burden (Hours)	90	90
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
eCarePlan Consent Information Sheet - SURVEY	eCarePlan Consent Information Sheet - SURVEY.pdf	11/30/2023
fast-track-PRA-submission-short-form Patient and Caregiver Survey	fast-track-PRA-submission-short-form Patient and Caregiver Survey.docx	11/30/2023

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