Anesthesia Patient Satisfaction Survey

Clearance for A-11 Section 280 Improving Customer Experience Information Collection

Documents and Forms

Document Name Document Type
Form Anesthesia Patient Anesthesia Patient Satisfaction Survey Form and Instruction
Form Anesthesia Patient Anesthesia Patient Satisfaction Survey Form and Instruction
Anesthesia Patient Anesthesia Patient Satisfaction Survey OMB Anesthesia Wireframe.pdf Form and Instruction
Anesthesia Patient Anesthesia Patient Satisfaction Survey OMB Anesthesia Wireframe.pdf Form and Instruction
ICR Template_A11 Section 280 Clearance.pdf Anesthesia Patient Satisfaction Survey IC Document
ICR Template_A11 Section 280 Clearance.pdf Anesthesia Patient Satisfaction Survey IC Document

Information Collection (IC) Details

IC Title:	Anesthesia Patient Satisfaction Survey	Agency IC Tracking Number:	2900-0876 Anesthesia

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Anesthesia Patient Satisfaction Survey	Anesthesia Patient Satisfaction Survey	OMB Anesthesia Wireframe.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Anesthesia Patient Satisfaction Survey	ICR Template_A11 Section 280 Clearance.pdf	08/04/2023

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