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Federal forms, ICRs, and supporting documents

Information Collection

Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QI) Customer Survey

IC 233835 under ICR 202501-0935-001 · OMB 0935-0179.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

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Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QI) Customer Survey
 
Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 Web-based Survey Customer Satisfaction Survey_Patient FINAL.docx Yes Yes Fillable Fileable

Health Health Care Services

 

300 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 300 0 0 0 0 300
Annual IC Time Burden (Hours) 50 0 0 0 0 50
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Supporting Statement OMB Clearance Attachment B Submission Form AHRQ QI survey_FINALMD_5.09.2018.docx 10/31/2018
Cover Letter Cover Letter.doc 10/31/2018
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.