Information Collection

Patient Services Survey

IC 213555 under ICR 202506-0906-005 · OMB 0906-0004.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Patient Services Survey	Form and Instruction
Form 1 OPA PSC Survey English Patient Services Survey	Form and Instruction
Form 2 OPA PSC Survey - Spanish Patient Services Survey	Form and Instruction
Attachment 2 - OPA PSC Survey English - OMB 0906-0004 - 06302025 - REDLINE.docx	Other-Redline
Attachment 2 - OPA PSC Survey English - OMB 0906-0004 - 06302025 - REDLINE.docx	Other-Redline
Attachment 4 - OPA PSC Survey Spanish - OMB 0906-0004 - 06302025 - REDLINE.docx	Other-Redline
Attachment 4 - OPA PSC Survey Spanish - OMB 0906-0004 - 06302025 - REDLINE.docx	Other-Redline
1 OPA PSC Survey English Attachment 1 - OPA PSC Survey English - OMB 0906-0004 - 06302025 - CLEAN.docx	Form and Instruction
1 OPA PSC Survey English Attachment 1 - OPA PSC Survey English - OMB 0906-0004 - 06302025 - CLEAN.docx	Form and Instruction
2 OPA PSC Survey - Spanish Attachment 3 - OPA PSC Survey Spanish - OMB 0906-0004 - 06302025 - CLEAN.docx	Form and Instruction
2 OPA PSC Survey - Spanish Attachment 3 - OPA PSC Survey Spanish - OMB 0906-0004 - 06302025 - CLEAN.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Yes	Yes	Fillable Fileable
Form and Instruction	2	Yes	Yes	Fillable Fileable
Other-Redline		Yes	Yes	Fillable Fileable
Other-Redline		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	153	153
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.

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