Information Collection

Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division

IC 223277 under ICR 202501-0935-001 · OMB 0935-0179.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	Form and Instruction
Form 1 Questions for Patient Key Informants Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	Form and Instruction
1 Questions for Patient Key Informants Customer Satisfaction Survey_Patient FINAL.docx	Form and Instruction
1 Questions for Patient Key Informants Customer Satisfaction Survey_Patient FINAL.docx	Form and Instruction
Generic Clearance Submission Patient Questions FINAL.doc Supporting Statement Part A	IC Document
Generic Clearance Submission Patient Questions FINAL.doc Supporting Statement Part A	IC Document
OMB Cover Letter.doc Cover Letter	IC Document
OMB Cover Letter.doc Cover Letter	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: Removed

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				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-40	40
Annual IC Time Burden (Hours)	-10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement Part A		08/31/2016
Cover Letter		08/31/2016

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].