Information Collection

19. Attachment U - Patient Toolkit Survey - Patient

IC 268507 under ICR 202406-0935-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 19 19. Attachment U - Patient Toolkit Survey - Patient	Form and Instruction
19 Patient Survey Attachment U - Patient Toolkit Survey - Patient.2024_5_24.docx	Form and Instruction
19 Patient Survey Attachment U - Patient Toolkit Survey - Patient.2024_5_24.docx	Form and Instruction

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	19	Patient Survey	Attachment U - Patient Toolkit Survey - Patient.2024_5_24.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: 62,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	62,500	62,500
Annual IC Time Burden (Hours)	5,208	5,208
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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